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0Q�Inspection Report Number <br />Waste Tire Survey & Inspection Rep <br />CalRec cle State of California <br />Y CalRecycle 181 (Rev. 10110) Survey Form -Page 1 1 -1226233 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />P rt A - Surve BLUE OR BLACK INK PEN <br />U <br />Business Profile <br />Inspection Details <br />TPID - O q I ` I _ m. <br />1 "1 J <br />Inspection Type (Fill one) <br />Site Suffix: ` <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />CalRecycle Q Complaint Q Educational Visit Q Other <br />Local '— <br />Identifier:d J �C�LLn��1 <br />(��1,(I utj (� <br />` ` <br />Q CHP Q <br />Inspected By Inspector <br />Business or Facility Name <br />Physical Address �l <br />3.'A0 �i < aQfo Le- <br />LoL CA D <br />r1 <br />Inspection Date <br />Time In Time Out <br />Business Rep Title <br />O AM 1 Q O AM <br />PM ® PM <br />-- <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />dire 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 />®Passenger <br />Q Altered <br />®Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />41 Truck <br />O <br />Longitude - <br />Q Planned <br />® OTR <br />Q End -Use <br />` Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />• 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 />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 EXE <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�01; cam! fs � 1 <br />Gs c f1\ <br />Inspection Form Included: Q <br />, q II ,,I <br />� `�� Vllo <br />jieness%es <br />Comments Included: ® <br />Signature Phone Number Inspeer,gnature Phone Number <br />INSTRUCTIONS N BACK Correct: Incorrect: JEXJA�L i 2 3 62081 <br />® White Copy: CalRecycle Yellow Copy: Operator Pink Co y' &A!A ■ <br />