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Waste Tire St ley & Inspection Reportonspection Report Number <br />CalRec cle State of California <br />Y CalRecycle 181 (Rev. 10/10)1255797Survey Form -Page 1 I1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Parr A _ Rgrvey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -I // 3 ,�1 <br />`� V (:) <br />Inspection Type (Fill one) <br />Site Suffix: <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Visit Q Other <br />Local _ <br />Identifier. <br />h JCaqu W <br />Q CHP Q CalRecycle Q Complaint Q Educational <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />44, U ley l r ga <br />U <br />1 � LG�5- S f� <br />Inspection Date � Z—/ U <br />` `� <br />Time In Time Out <br />Business Rep Title <br />t'j', <br />q I *AM r O AM <br />l � J <br />P / <br />i� ��✓w ��n.d <br />S <br />O PM PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) i 5� <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 />• Passenger <br />Q Altered <br />• Generator <br />Q Hauler <br />! Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />• Truck <br />O <br />Longitude - <br />Q Planned <br />I* 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 <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <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 />Compliance Deadline <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 />Date M/M/m <br />Q <br />® <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 />(Required for NOV or EX7) <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 Referred / CalRecycle Enforcement <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 />® In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments T �C - C0_4 <br />all" G� TLC. <br />u•A—e—, Lk,rck,o u i <br />`1� llGw 1���CX�- <br />Inspection Form Included: Q <br />V' <br />A <br />Comments Included: <br />'A__L�JLX' <br />Business Rep's atLke I Phone Number Inspector's Signature Phone Number <br />I <br />I1111111111EM <br />INSTRUCTIONS ON BACK <br />Correct: <br />Incorrect: X V <br />EXAMPLE 1 2 3 <br />62081 <br />0 <br />White Copy: CalRecycle <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />I <br />I1111111111EM <br />