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0 2 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />CalRecycle State of California <br />CalRecycle 181 (Rev. y (Cal Survey Form - Page 1 1 1230426 <br />Dept of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - <br />Site Suffix: <br />Local <br />Identifier: <br />Inspection Type (Fill one) <br />S 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 />Business or Facility Name ( Inspected By Inspector <br />Physical Address <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V F A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of I ires <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 />Inspection Date 4 / <br />0 <br />y <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 />Time In <br />Time O -u <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Business Rep <br />Title <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O AM <br />0 <br />I <br />O AM <br />0 <br />0 <br />Other: § <br />- L e PM <br />.* PM <br />- -- - -- - - - <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />0 Active <br />(Fill all that apply) <br />0 Passenger <br />(Fill all that apply) <br />0 Generator <br />(FII all that apply) <br />40 Outdoor <br />�PS Latitude <br />O <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />O <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />• 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 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 F A HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of I ires <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 />ENFORCEMENT STATUS <br />0 Notice Of Violation 6Extension <br />Compliance Deadline <br />Datem/ M <br />/m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />Comments <br />Inspection Form Included: (_y/� /�� �` v ,,��i <br />Comments Included: <br />I Business Reo's Sionature Phone Number Inspec is Signature <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X * V EjXjAjMj P I LJEJ 1112 3 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />Ri <br />W <br />Phone Number <br />62081 <br />® ■ <br />