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i <br />Waste Tire Su, vey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev.y (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Sart A - Survey <br />Business Profile Inspection Details <br />Inspection Report Number ■ <br />11 - 1177954 <br />BLUE OR BLACK INK PEN <br />TPID - Inspection Type (Fill one) <br />Site Suffix: & 1 ® Routine 0 Re -inspection 0 Referral 0 Observation <br />Local <br />Identifier: �`-� �� �' <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 <br />0 <br />0 <br />Inspected By <br />0 <br />Inspector <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />s. <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />3 9 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Physical Address <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 />( <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 />Inspection Date <br />1 / <br />© L� / <br />i Z <br />Comments - <br />CA <br />Time In <br />Time Out <br />Business Rep <br />Title <br />02 ' J <br />} 0 AM <br />LI ®PM <br />p2 <br />1 0 AM <br />l ®PM <br />Al <br />-_ - <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE)(Fill <br />9 <br />75 <br />one only) <br />0 Active <br />(Fill all that apply) <br />0 Passenger <br />(Fill all that apply) <br />0 Generator <br />(Fill all that apply) <br />A* Outdoor <br />GPS Latitude <br />O <br />0 Closed <br />0 Altered <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />Longitude - <br />O <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />_ <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet <br />0 Government 0 Retreader <br />0 Dismantler 0 Tire Derived Fuel <br />(V 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 I <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 />0 <br />Other: § <br />Comments - <br />S� <br />Inspection Form Included: 0 <br />Comments Included: ®QA1jn,5&j 40- <br />Business ignature Phone Number <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <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 />Lu <br />Phone Number <br />62081 <br />® ■ <br />