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0 0 Waste Tire Survey & Inspection Report Inspection Report Number <br />CalRecycle State of California <br />CalRecycle 181 (Rev. 10/10)Survey Form o page 1 I1 -1210585 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - Inspection Type (Fill one) <br />Site Suffix: ' Lt t-1 i� o ® Routine Q Re -inspection Q Referral Q Observation <br />Local L <br />Identifier:'~ �CG�`./1 LXilry <br />Business or Facility Name <br />Physical Address <br />6qt & <br />C�=V� <br />Business Rep <br />i vxavn i <br />Tire Count (Whole/PTE) <br />G+PS Latitude <br />Longitude <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair <br />® Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <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 />6 `�'t - 0 1 A-1kA+1Cyu /+ <br />Q Trucking Fleet U Government U Retreader () Dismantler () Tire Derived Fuel <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder Q Other <br />Part <br />Inspection Date <br />-7 / <br />V <br />A <br />C �SdJE� <br />Q <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Time In <br />PRC § 42956 - Registration/Decal in Vehicle <br />Time Out <br />Q <br />Title <br />Q <br />(a AM <br />,/ 181' AM <br />CL <br />Q <br />X <br />0 Q PM <br />l <br />O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 <br />® Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />& Outdoor <br />Q Indoor <br />0 <br />Q Inactive <br />Q Truck <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Trucking Fleet U Government U Retreader () Dismantler () Tire Derived Fuel <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />HAULING AND MANIFEST REQUIREMENTS <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />V <br />A <br />Q <br />Q <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <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 />® <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 <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 />010 <br />Other: § <br />Comments <br />Inspection Form Included: U <br />Comments Included: <br />Business R s ignature Phone Number sp <br />INSTRUCTIONS ON BACK I Correct: I, Incorrect: X q E f <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink <br />ENFORCEMENT STATUS <br />® Notice Of Violation Q Extension <br />Compliance Deadline <br />Date [JC.% / IiN / F, fl --5 <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />Q In Compliance - No Violations <br />Phone Number <br />62081 <br />® ■ <br />