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Waste Tire Avey & Inspection Reporpinspection Report Number <br />CalRec cle State of California <br />Y CalRecycle 181 (Rev. 10/10)SurVey Form -Page 1 I1 1210264 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />lo—+ A _ c(SLUE OR BLACK INK PEN <br />4� <br />Business Profile <br />Inspection Details <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: 0 4 6 1-1 -7 �5_ Q l <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local C_� <br />Identifier: Zic -S�Lct"qV� ��v►`l. <br />l <br />Business or Facility Name <br />Inspected By Inspector <br />Physicaf Address <br />h6 Itri t32>.L-1� <br />Inspection Date / ✓ C / ) 3 <br />LSC; <br />Time In Time Out <br />Business Rep Title <br />AM (0 AM <br />Q PM { 1 0 PM <br />`,�_, <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that a'"pply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (VNhole TE j D <br />a Active <br />Q Closed <br />& Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />Q Outdoor <br />Q Indoor <br />O <br />��� Latitude <br />Q Inactive <br />Truck <br />O <br />Longitude - <br />Q Planned <br />OTR <br />Q End -Use <br />® Container <br />Business Type (Fill all that apply) <br />® 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 />Q Notice Of Violation Q Extension <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 />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 />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 />(Required for NOV or EXT) <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 <br />Inspection Form Included: Q ' <br />Comments Included: a `� <br />kes Rep's gnatu a Phone Number Ins a or' I ature Phone Number <br />�( 62081 <br />INSTRUCTIONS N BACK Correct: is Incorrect: ^/ W NJ E X A L 1;2 3 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Co y: L ® ■ <br />