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Waste Tire Su, vey & Inspection Report inspection Report Number ■ <br />State of California <br />CalRecycle A ul Yep� I 1 -1210469 <br />CalRecycle 181 (Rev. y Form — Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Sv <br />)art A - Survey BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />- <br />Site 0 ( 1 <br />Site Suffix: 0 <br />Local <br />dentifier: CU -64 11 <br />Business or Facility Name l <br />N e.Se <br />Physical -Address ) <br />Business Rep Title y, <br />�JeoC_ \��(A-S <br />Tire Count (Whole/PTE) `, -Z <br />O <br />GPS Latitude , <br />O <br />Longitude - <br />Business Type (Fill all.that apply) <br />0 New Tire Dealer ® Auto Repair <br />0 Used Tire Dealer 0 Auto Body <br />0 Service Station 0 Hauler <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />EST REQUIREMENTS <br />mspecuon type trw one) <br />® Routine O Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />O CHP O CalRecycle O Complaint O Educational Visit O Other <br />Inspected By Inspector <br />3 - � 01 GSM7TO <br />Inspection Date <br />Time In <br />A <br />HAULING AND MANIF <br />AAM <br />0 Notice Of Violation 0 Extension <br />PM <br />Operational Status <br />Tire Type <br />(Fill one only) <br />0 <br />(Fill all that apply <br />® Active <br />Compliance Deadline <br />0 Passenger <br />O Closed <br />PRC § 42956 - Registration/Decal in Vehicle <br />O Altered <br />0 Inactive <br />0 <br />0 Truck <br />O Planned <br />0 OTR <br />0 Trucking Fleet 0 Government U Retreader <br />0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Agriculture 0 Shredder 0 Other <br />� a / ) 3 <br />Time Out <br />T O AM <br />1 5 J ® PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator • Outdoor <br />O Hauler 10 Indoor <br />0 End -Use 10 Container <br />Dismantler <br />Tire Derived Fuel <br />V <br />A <br />HAULING AND MANIF <br />0 Notice Of Violation 0 Extension <br />O <br />O <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 />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 />O <br />O <br />I Other: § <br />Comments 4 1 us J" <br />INU 1/1nlGtl rte U�CtAS��S M <br />Inspection Form Included: <br />/;;W <br />Comments Included: y -- <br />Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect:E X A M P 1 Z 3 62081 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: W 0 <br />z <br />0 <br />z <br />