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a <br />Waste Tire Owey & Inspection Repay L Inspection Report Number ■ <br />cle State of California <br />Cal Rec <br />Y CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 I1 -1226219 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />'art A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -Inspection _ O Inspection Type (Fill one) <br />Site Suffix: I ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local �\ / <br />Identifier: s6kn <br />Business <br />o. -r Facility Name <br />Physical Add 0+ LcA ( O <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By I Inspector <br />3 l -1 1 CS C-06 <br />���` C7p <br />1 <br />� <br />I���� <br />Inspection Date <br />Time In <br />� / <br />a (.0 / <br />Time Out <br />I <br />Business Rep <br />TitleAM <br />c) <br />5 <br />�\ <br />I U <br />• AM <br />0 <br />((�JJ <br />S ucy % (�bn SAA P_ <br />�A�n�LllwnCc <br />PRC § 42956 - Registration/Decal in Vehicle <br />QPM <br />0 <br />Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Tire Count (Whole/PTE) <br />0 <br />0 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />�J <br />0 Active <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />4j Closed <br />% d Q <br />0 Altered <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />GPS Latitude <br />Other: § <br />Comments n <br />Hauler <br />0 indoor <br />0 Inactive <br />0 Truck <br />Longitude — <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill ail that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />41 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body <br />0 Car Dealer <br />0 Collection 0 Crumb <br />Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture <br />0 Shredder 0 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 />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments n <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />• In Compliance - No Violations <br />11 �l O vii ; .,s o r to I < i WNSL-n `J <br />1A�,, �-i �- E. 6)w Ave LA�h(��, c A . <br />Inspection Form Included: 0 <br />Comments Included: 0 �� 1 <br />Business Rep's Signature Phone Number t1nsp tor's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: � AM t E 1 2 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy L © 0 <br />