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Waste Tire Sull vey & Inspection Repos L 'Inspection Report Number ■ <br />Cal Recycle State of California I 1' 1196422 <br />CalRecycle 181 (Rev. y(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />aar+ A - Riwito.. BLUE OR RLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Q <br />TPID -/ U <br />Site Suffix: b -1 <br />� � <br />� g � _ <br />O � <br />Inspection Type (Fill one) <br />Q Routine ® Re -inspection Q Referral Q Observation <br />Local C <br />Identifier: �SCA� a�L� �� \ C O�N�h-/ <br />l <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />Q <br />' ; <,Jlnao Ls zz. E <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />Q <br />Phy/sica ddress <br />Q <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 />J1z��.�� <br />Lei <br />�SJo� <br />Inspection Date <br />J <br />Time In <br />Time Out <br />Business Rep <br />Titll�e1 <br />® AM <br />®AM <br />✓J <br />1 <br />l I : Z Q O PM <br />Q PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />L� <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />' <br />® Active <br />Q Closed <br />• Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />o <br />CaP$ Latitude <br />Q Inactive <br />Q Truck <br />Longitude — <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />® New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q 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 />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <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 />Q <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 />() <br />() <br />Other: § <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />Business <br />Phone Number <br />INSTRUCTIONS ON BACK Correct:0 Incorrect: <br />® White Copy: CalRecycle Yellow Copy: Operator Pink <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />®In Compliance - No Violations <br />1�9— <br />Phone Number <br />62081 <br />