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Waste Tire S►.. vey & Inspection Reporill. Inspection Report Number ■ <br />State of California <br />CalRecycle 11 - 1226600 <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Inspection Type (Fill one) <br />(a Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />TPID - <br />Site Suffix: J i 1� <br />—1 y <br />Local c� ` <br />Identifier: -�C.�� J�.i���1�� �-wr �,, <br />i� <br />t�j <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />l <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />- <br />&J.vl t� A <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Physical Address <br />' <br />t 0 i �� �n baC,\,- <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />g5,o3 <br />Inspection Date ! .CJ -r1 <br />1 <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Time In Time Out <br />Business Rep <br />Title <br />Q <br />0 AM *AM <br />D - Z _5 O PM rJ - Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Active <br />a Closed <br />6 Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />GPS Latitude <br />0 <br />Q Inactive <br />Q Truck <br />Longitude - <br />0 <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />7 <br />Q Shredder ® Other �� ee t SC�� t ��✓ - <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 />O <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 <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />®In Compliance - No Violations <br />Inspection Form Included: U <br />Comments Included: * A --- ---- <br />Business I Signature Phone Number I p or' gnature <br />INSTRUCTIONS ON BACK Correct:* Incorrect: E X AMP L E <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Y.Z <br />Phone Number <br />2 3 62081 <br />© ■ <br />7 <br />0 <br />