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Waste Tire F' ley & Inspection Repo Inspection Report Number ■ <br />State of California <br />CalRecycle 11 - 1226534 <br />CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey_ BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />TPID - p <br />Site Suffix: Gf f 3 C/ d l <br />Local <br />Identifier: <br />Business or Facility Named <br />S-{-�c�c#-ur, �ccw�Gjcr-S <br />Physical Address <br />i a Yo Alavvc D, <br />7fD k i cJr1 <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude - <br />Business Tvoe (Fill all that aooly) <br />C 11 9sa06 <br />Title AA <br />! <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />c - % <br />0/ 4j06er i FN <br />Inspection Date j C / 3 ! <br />Time In Time Out <br />Q New Tire Dealer <br />0 AM 0 AM <br />% S S O PM S_ ® PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q Auto Body <br />Q Car Dealer <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Agriculture <br />® Active <br />Q Passenger <br />® Generator <br />Q Outdoor <br />a <br />Q Closed <br />Q Altered <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 Hauler <br />®Indoor <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Inactive <br />® Truck <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />o <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q New Tire Dealer <br />Q Auto Repair <br />® Trucking Fleet <br />Q Government <br />Q Retreader <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />® Collection <br />Q Crumb Rubber <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />I 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 <br />Inspection Form Included: Q <br />Comments Included: <br />Business epLgna Phone Number Inspector' <br />INSTRUCTIONS ON BACKCorrect:0 incorrect: <br />White Copy CalRecycle Yellow Copy: Operator Pink Copy <br />Dismantler n Tire Derived Fuel <br />AllL r/c <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 />Czmy-) Y6 V'd6 <br />Phone Number <br />62081 <br />N <br />N <br />N <br />a <br />LU <br />W <br />