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03 Waste Tire Sw vey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev. 10/10) <br />(Cal Survey Form - Page 1 <br />Dept, of Resources Recycling and Recovery (CalRecycle) <br />)art A - Survey <br />Business Profile Inspection Details <br />TPID - <br />Site Suffix: <br />Site <br />( / <br />V <br />S o 6 <br />Time In <br />_V <br />Local <br />Identifier: <br />HAULING AND MANIFEST REQUIREMENTS <br />--- - <br />Q Notice Of Violation Q Extension <br />Business or Facility Name <br />p 2 - a <br />WVv, -\-Y <br />VZb Co Az-ok-0 W_O V <br />Physical Address <br />'Z3ti5 Now Oc. <br />Business Rep <br />PrCk-h& 13e <br />Tire Count (Whole/PTE) <br />s <br />GPS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />CA X152 of <br />Title <br />%Vl ar e <br />2. O 7 <br />Q Trucking Fleet <br />Q Car Dealer <br />Q Agriculture <br />0 <br />Inspection Report Number <br />Il -1210233 <br />BLUE OR BLACK INK PEN <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 />- 0 1 MA-TTQ <br />Inspection Date <br />( / <br />V <br />-,�! 7 <br />Time In <br />_V <br />Time Out <br />HAULING AND MANIFEST REQUIREMENTS <br />--- - <br />Q Notice Of Violation Q Extension <br />Q <br />` <br />• <br />0 P <br />Q <br />7PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />® Passenger <br />0 Generator <br />• Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />ID Truck <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />U Government <br />Q Collection <br />Q Shredder <br />Q Retreader <br />Q Crumb Rubber <br />Q Other <br />Dismantler 0 Tire Derived Fuel <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />_V <br />_A <br />HAULING AND MANIFEST REQUIREMENTS <br />--- - <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC 42951 Waste Tire Hauler Registration and Transport of Tires <br />§ - <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <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 />(Required for NOV or EXT) <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 Referred / CalRecycle Enforcement <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 />10 In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />Inspection Form Included: U �>r12�91-11,169161 <br />/'4414� �- `� G q- <br />��� 3-294 <br />Comments Included: SI �'" <br />1 Bu iness Rep's Signature Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X� qjjEjXjAjMjPjLjEj 1112 3 62081 <br />FF a <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />y <br />T <br />CN <br />N <br />0 <br />W <br />W <br />