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Waste Tire Sui vey & Inspection Report Inspection Report Number <br />CalRecycle State of California 11 - 1230237 <br />CalRecycle 181 (Rev. to/to) Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />o„-. n c.....,.., RI IIF nR RLACK INK PEN <br />Business Profile <br />Inspection Details <br />A <br />TPID - <br />o <br />Inspection Type (Fill one) <br />Site Suffix: <br />1* Routine Q Re -inspection Q Referral Q Observation <br />Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />LocalIf <br />Identifier: (�ar 3-oci-I %;% Y-\ c'\z, <br />Business or Facility Name <br />Inspected By Inspector <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Physical Address <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />�� V <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 />Inspection Date / <br />O -) / I <br />Q <br />Time In <br />Time Out <br />Business Rep Title <br />, O AM <br />5 O PM <br />� O AM <br />o S PM <br />f p'�/� r <br />h1M e` <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />IS <br />l.�V J `Gl <br />PTE) ''L <br />Tire Count (Whole 5 o <br />Active <br />Q Closed <br />0 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 />0 OTR <br />Q End -Use <br />0 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 />0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br />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 />010 <br />Other: § <br />Comments V _ � , _ „ . _ _ t — k'_ — <br />n vl� 1� K_C�Ikx ell 1's %'rte c .XnkS <br />►'tCS�n� iOri� <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/ M/m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />In Compliance - No Violations <br />3 <br />Inspection Form Included: I�L_ 0�� <br />Comments Included: <br />us&4' � � N�� )(20' <br />inesi R 's ignature Phone Number Inspector's Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: g E X A M P L E 1 2 3 <br />White Copy CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />CV <br />0 <br />Lu <br />Lu <br />