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Waste Tire Su. ,iey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev.y (Ca[ Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A - Survey <br />Business Profile Inspection Details <br />Site Suffix: I <br />Local <br />Identifier: "tXy, 3 <br />Business or Facility Name 1 <br />009 �;�. Co QAY ACAV_'%r Px�l I <br />Physical Address <br />N1►'� S. W-, so,,\ u °)r <br />Inspection Report Number ■ <br />I1 - 1210128 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <br />• Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />S� ' %M ` cA- I JG 6 Inspection Date / <br />Business Rep <br />Tire Count (Whole/PTE) <br />e <br />GPS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />U Trucking Fleet 0 Government <br />0 Car Dealer 0 Collection <br />0 Agriculture 0 Shredder <br />I q / t 3 <br />Time Out <br />Q AM <br />© 40 PM <br />Business Role <br />Time In <br />Title <br />U O AM <br />' <br />Sin G-F� r� <br />1 PM <br />Operational Status <br />Tire Type <br />— <br />1 <br />(Fill one only) <br />(Fill all that appli <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />0 <br />. <br />0 Inactive <br />0 Truck <br />O <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 Planned <br />0 OTR <br />U Trucking Fleet 0 Government <br />0 Car Dealer 0 Collection <br />0 Agriculture 0 Shredder <br />I q / t 3 <br />Time Out <br />Q AM <br />© 40 PM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Generator <br />0 Outdoor <br />0 Hauler <br />40 Indoor <br />0 End -Use <br />0 Container <br />U Retreader U Dismantler <br />0 Crumb Rubber <br />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 />1 0 <br />Other: § <br />Comments _ <br />Inspection Form Included: 0 <br />Comments Included: <br />Business Re 's Signature <br />Tire Derived Fuel <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 />5 A.c NCPct� rl� 6-!sv'CC(- <br />g- 305 �� <br />Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: NJ <br />White Copy: CalRecycle Yellow Copy: Operator <br />E X A M P L E 1112 3 62081 <br />Pink Copy: LEA © <br />■ <br />