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0 0 Waste Tire Su. Bey & Inspection Repor, <br />CalRecycle state of California <br />CalRecycle 181 (Rev.y H0) Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Si irvav <br />Inspection Report Number <br />11 - 1..17680• <br />BLUE OR BLACK INK PEN <br />Business Profile <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <br />Inspection Details <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />TPID - <br />Site Suffix: �j q '8 <br />l <br />Inspection Type (Fill one) <br />0 <br />C2 <br />PRC § 42956 - Registration/Decal in Vehicle <br />V <br />® Routine 0 Re -inspection 0 Referral <br />If Referral, choose referral type (Fill one) <br />0 Observation <br />Local <br />Identifier: V ` wv► L' I <br />` <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />( <br />0 CHP 0 CalRecycle 0 Complaint <br />0 Educational <br />Visit 0 Other <br />Business or Facility Name <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />Inspected By Inspector <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />Physical Address <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 />Inspection Date `� / <br />. -� �,. � / <br />Time In <br />Time Out <br />Business Rep <br />Title <br />O AM <br />PM <br />F ' O AM <br />lJ ® PM <br />c�Xrynj <br />p2 J l &I <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />17, <br />Tire Count (Whole/PTE)14100 <br />41 b l.,r / <br />(Fill one only) <br />0 Active <br />(Fill all that apply) <br />0 Passenger <br />(Fill all that apply) <br />Generator <br />(Fill all that apply) <br />0 Outdoor <br />GPS Latitude <br />O <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />O <br />Q Inactive <br />Q 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 />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />® 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 <br />A <br />I 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 />® <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 />Comments <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date / P�] / <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: Q <br />i ,0 <br />Comments Included: <br />EjUsineo ReA Signature one Numbe Ins r n lure Phone Number <br />62081 <br />INSTRUCTIONS O j <br />Corr c Incorrect: E X M E 1112 3 <br />■ White Cop Cal cle Yellow Copy: Operator Pink Copy: LEA ■ <br />0 <br />z <br />u <br />