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Oa Waste Tire S.„ vey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Rurvpv <br />Inspection Report Number <br />I1 -1177897 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />TPID - 1 SInspection <br />Site Suffix: l y 3 <br />(0 <br />Type (Fill one) <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />0 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />Local / �- <br />Identifier: S <br />J <br />An G �� �; ,-` WLlfl�t� <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 CHP 0 CalRecycle 0 Complaint <br />0 Educational <br />Visit 0 Other <br />Facility Name <br />Business or(-l`C1 f i c} �� <br />0 <br />Inspected By I Inspector <br />0 <br />0 <br />e <br />Physical Address J <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />1 sao 5- A LA1 V� - 1 <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 />() <br />n <br />\J / � <br />1►'"L 1 <br />� �Z� • <br />S <br />Inspection Date l 0 <br />J <br />Time In <br />Time Out <br />Business Rep Title <br />(8 AM <br />1 f, v <br />® AM <br />I V S 5 <br />L I , 1 <br />Fly m��I�r. T <br />d` V QPM <br />QPM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />lC W C. 2.r <br />Tire 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 />0 Closed <br />0 Passenger <br />0 Altered <br />0 Generator <br />0 Hauler <br />0 Outdoor <br />®Indoor <br />GPS Latitude <br />0 Inactive <br />` Truck <br />Longitude - <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 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 />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 />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 />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 />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 <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 />() <br />n <br />Other: § <br />Comments I�b1�1 �l1a w 1, s+` -f1 <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />Inspection Form Included. 0 �I " ,l <br />Comments Included: —3 <br />;;fus'iness Rep's Signature Phone Number Insp toy's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: k*IVJE I X A 1112131 62081 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LE <br />L;i <br />N <br />C1 <br />0 <br />Lu <br />Lu <br />