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0 Waste Tire Spe & Inspection,Re orpinspection Report Number <br />CalRecycle state of California Y_ <br />CalRecycle 181 (Rev. 10/10) Survey Form Page 1 I1 1245294 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part e - Cimiaw BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />Q <br />TPID - 1 3 t , _ <br />Site Suffix: "� <br />O 1 <br />Inspection Type (Fill one) <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local t^ <br />Identifier: <br />Q CHP Q CalRecycle Q Complaint <br />Q Educational Visit Q Other <br />Business or Facility Name <br />Q <br />Q <br />Inspected By Inspector <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />Physical Address <br />Q <br />Q <br />? <br />A -G /fj I 1 <br />`1 5 ZD S• �-,�ln W o� <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />S�cI�-�C;t^ <br />C- <br />q52 lS <br />Inspection Date 0 g <br />19 1 C' <br />1 J <br />Time In <br />Time Out <br />Business Rep <br />Title <br />/h) 0 AM <br />0 AM <br />1 I* <br />V PM <br />PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />' <br />' <br />3 <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />41 Generator <br />Q Hauler <br />A Outdoor <br />0 Indoor 14 <br />O <br />GPS Latitude <br />Q Inactive <br />0 Truck <br />Longitude - <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />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 />Q <br />Q <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / m / m <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />S In Compliance - No Violations o <br />A <br />Inspection Form Included: <br />Comments Included: 5- L,�L_ 31 <br />49-0 <br />Business Rep Signature Phone Number Insp tor's Signature <br />INSTRUCTIONS ON BACK Correct: Incorrect: � E X A M P L E 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />q _V (E-3 2 <br />Phone Number <br />62081 <br />