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Waste Tire J Ivey & Inspection Repoi <br />Cal Recycle State of California <br />CalRecycle 181 (Rev. 10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Pa►t D - Cnrmwu <br />Inspection Report Number <br />I1 - 1242139 <br />RLIIF OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />TPID - <br />Inspection Type (Fill one) <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Site Suffix: I 5 Z1 S ® 11 ( <br />Q Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q Other <br />Local`n C <br />Identifier: JIXe/1� <br />v 0 <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational <br />Visit <br />Business or Facility Name <br />Inspected By Inspector <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 />Physical Ad ress <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />j,�/ ` � ,gyp <br />15--5cS M I 4v -e-- <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />LU l yl� � �530� <br />Inspection Date <br />1 <br />"l <br />Time In <br />Time Out <br />Business Rep Title <br />0 AM <br />/ 2_; c;20 ® PM <br />l 5 <br />0 AM <br />® PM <br />LL ,,/ <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />O <br />Q Inactive <br />0 Truck <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q. Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture 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 />Q <br />Q <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m /m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />i <br />Inspection Form Included: Q G <br />Comments Included: 0a>7 <br />B sines ep's Signature Phone Number lnseqfo s gna re Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: ?�/ � E I X AMP 1 2 13 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy LE <br />R <br />GV <br />0 <br />Lu <br />Lu <br />