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Waste Tire Su, vey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev.y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Survey <br />A - Giirvav <br />Inspection Report Number <br />I1 - 1245089 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID -f C.J <br />Site Suffix: ® Z L/ <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: ��/� <br />�v V i lrl <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By <br />Inspector <br />Ph-ysic�al Address <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Inspection Date <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Time In <br />Time Out <br />Business Rep Title <br />++ 0 AM <br />' I <br />0 AM <br />O PM <br />JZ4^ �- <br />PM <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) � � � "� <br />(Fill one only) <br />& Active <br />Q Closed <br />(Fill all that apply) <br />a Passenger <br />Q Altered <br />(Fill all that apply) <br />® Generator <br />Q Hauler <br />(Fill all that apply) <br />� <br />I& Outdoor <br />Q Indoor <br />GPS Latitude <br />O <br />Q Inactive <br />Q Truck <br />Longitude — <br />Q Planned <br />e OTR/ <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />6 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler <br />Q Tire Derived Fuel <br />O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments K`� to +' i�� 'i <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / IT <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />" 11�2 LLi <br />Inspection Form Included: Q ^ 1 <br />Comments Included: <br />Business Rep's Signat Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: EjXjA�MjPjLjEj 1112 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA © 0 <br />N <br />0 <br />W <br />W <br />