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Oa Waste Tire Sup vey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. 10/10) <br />(Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />)art A - Survey <br />Business Profile Inspection Details <br />TPID - 1 <br />Site Suffix: <br />Local <br />Identifier: <br />3 5 -7 <br />SCA -Y., Ioo-c� 0, V-11, C�_ - <br />Business or Facility Name <br />Physical Address v` <br />S �oGV\-e>n <br />Business Rep Title <br />G,ke. (_. lW e.6 e (- Re <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude <br />ql <br />C A GS21S <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Service Station 0 Hauler 0 Agriculture <br />,nspection Report Number <br />11 - 1210160 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <br />• 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 />Inspected By Inspector <br />- � 0 1 MA -T -T\) <br />Inspection Date - / 30/ 1 3 <br />Time In Time Out <br />I 0 A j 0 A <br />AL DKA QPM <br />. <br />Storage Type <br />(Fill all that apply) <br />*Operational Status <br />Tire. Type <br />0 Outdoor <br />( <br />(Filhone only) <br />(FII all that appl <br />1 <br />4 Active <br />0 Passenger <br />0 <br />0 Closed <br />0 Altered <br />0 <br />0 Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />U Government <br />0 Collection <br />0 Shredder <br />U Retreader <br />0 Crumb Rubber <br />0 Other <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />• Generator <br />0 Outdoor <br />0 Hauler <br />0 Indoor <br />0 End -Use <br />0 Container <br />Dismantler C ) Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Notice Of Violation � Extension <br />0 <br />0 <br />- and <br />PRC § 42951 Waste Tire Hauler Registration d Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />00 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date <br />m <br />/ <br />Ffl <br />/ <br />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 EX7) <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 />1 0 <br />1Other: § <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />Phone Number <br />z 10 <br />68- 3*q <br />Phone Number <br />® <br />INSTRUCTIONS ON BACK �Correct:e Incorrect: <br />White Copy: CalRecycle Yellow Copy: Operator <br />EXAMPLE 1 2j3 <br />62081 <br />® <br />■ <br />Pink Copy: LEA <br />2 <br />