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Waste Tire Survey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. (cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survev <br />Inspection Report Number <br />I1 - 1242146 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: l 0 Is® 5 g d l <br />® Routine 0 Re -inspection 0 Referral 0 Observation <br />Referral, choose referral type (Fill one) <br />O CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />LocalIf <br />Identifier: �a� ��G��,^V9®Wti� <br />Business or Facility Name <br />Inspected By Inspector <br />Y1w y-UC'6k'yA� <br />- <br />Physical d ress <br />l KA yn 6 Lt -A <br />Inspection Date <br />C•� <br />L-u,-�,� &A 633 p <br />t° <br />Time In Time Out <br />Business Rep Title <br />®AM 0 AM <br />� Z � �l ®PM <br />-�'YV\ Ole <br />I - men �- <br />0 P <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 />le Active <br />0 Closed <br />0 Passenger <br />O Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />® Truck <br />O <br />Longitude - <br />0 Planned <br />O OTR <br />O End -Use <br />O Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture O Shredder 0 Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A I <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m / m <br />0 <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CalRecycle Enforcement <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />0 <br />Other: § <br />Comments <br />0M t n c o, L's ri4l, <br />Inspection Form Included: Q <br />_. 6 <br />_F16 7 <br />Comments Included <br />Business Rep's ature Phone Number s s S nature Phone Number <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: X E A M P E J112131 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: FY ® ■ <br />C. <br />