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Waste Tire Survey & Inspection Reporl. Inspection Report Number . <br />Cal Rec cle State of California <br />Y CalRecycle 181 (Rev. 10/10)Survey Form -Page 1 1 -1226599 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />. ^___._-- BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />Inspection Type (Fill one) <br />Site Suffix: L Q O , <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/ - <br />Identifier: ,�1� �a��' �%� �-(A_I/V�q <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />Inspection Date <br />t <br />Time In TimeOut` <br />Business Rep Title <br />41 6. AM <br />B AM 1 ® O PM <br />� v L 4,: O PM � ( � .� G <br />(� <br />Av %�r C..,V l�i'� <br />Operational Status <br />(Fill one only) <br />®Active <br />Tire Type <br />(Fill all that apply) <br />40 Passenger <br />Business Role <br />(Fill all that apply) <br />®Generator <br />Storage Type <br />(Fill all that apply) <br />®Outdoor <br />Tire Count (Whole/PTE) <br />-43 0 <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />O <br />Longitude - <br />Q Planned <br />Q OTR <br />Q111 End -Use <br />Q 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 />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 ® 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 />O <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 />(Required for NOV or E)CT) <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 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 />Other: § <br />.0 <br />.0 <br />Comments <br />f' CLi' 1'1 V✓l Y1, <br />Inspection Form Included: Q <br />/ -�_. <br />Comments Included: ® <br />,) {� <br />-777 �D`'i - �6 <br />Business Rep's Signature Phone Number s ct ' ig at a Phone Number <br />-- - —— <br />INSTRUCTIONS ON BACK <br />Correct: IS Incorrect: ( <br />E <br />X <br />A <br />M <br />P <br />L- <br />El <br />I <br />62081 <br />0 White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />1_1V1 <br />C' <br />9 <br />0 <br />