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02 Waste Tire Su, vey & Inspection Report Inspection Report Number ■ <br />CalRecycle State of California — <br />CalRecycle 181 (Rev. 10/10) Survey Form -Page 1 I1 1226346 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />o,,..,. n c.....—, BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -I M G ry I - U, <br />�j J `� <br />I <br />Inspection Type (Fill one) <br />Site Suffix: <br />II* Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local <br />Identifier: 'Sa 70 C�(� <br />6t, u <br />` <br />Inspected By Inspector <br />Business or Facility Name <br />n L <br />1 ' cc S I� Lt"I j� � i S � I c.T <br />3 - 0 ►� <br />I G�I <br />Physical Address <br />DSV <br />C . <br />���//JJ <br />Inspection Date 3 <br />Time In Time Out <br />Business Rep Title <br />AM <br />I 0 I <br />�G�f �ti✓i S c�l�ner's 1-t�,''�"G <br />QPM Q PM <br />- <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) S d <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />0 Closed <br />a Passenger <br />0 Altered <br />0 Generator <br />0 Hauler <br />® Outdoor <br />Indoor <br />GPS Latitude <br />0 Inactive <br />0 Truck <br />0 <br />Longitude - <br />0 Planned <br />0 OTR <br />End -Use <br />0 Container <br />Business Type (Fill all.that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader • 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 0 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 <br />HAULING AND MANIFEST REQUIREMENTS <br />-- <br />0 Notice Of Violation 0 Extension <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/m/m <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 Referred / CalRecycle Enforcement <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />In Compliance - No Violations <br />0 <br />0 <br />Other: <br />Comments(�1(ijLL—aj1� <br />_��AQ Vt-O1—fNm I A) (A�� <br />- <br />Inspection Form Included: 0 <br />Comments Included: ®- <br />�}7 <br />- {>il 1> —� - <br />Busi ess p s Ignature _ Phone Number ` Inspe is Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: (� EXAM L 1 2 b'LUtSI <br />3 ® ■ <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: E <br />