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02 Waste Tire SAey & Inspection Report <br />CalRecycle State of California <br />CalRecycle 181 (Rev. (Cal Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Surwav <br />.nspection Report Number <br />I1 - 1242255 <br />BLUE OR BLACK INK PEN - <br />Business Profile <br />Inspection Details <br />TPID -1 /� <br />O � O � � <br />Site Suffix: p ` <br />Inspection Type (Fill one) <br />'6 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />2�� '� � �cev��n,� S�• <br />ed <br />�� �s" L� <br />Inspection Date <br />V <br />Time In Time Out <br />Business Rep Title <br />10 AM *AM <br />lJ Q PM <br />��� • `��� �� ` <br />Q PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) 1 <br />0 Active <br />Q Closed <br />0 Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />• Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />0 Truck <br />0 <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <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 />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m <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 />(Required for NOV or EX7) <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 Referred / CalRecycle Enforcement <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 />• In Compliance - No Violations <br />Q <br />Q <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />`LI <br />'(b 4or'sSig—nature <br />Comments Included: <br />u ne Rep's Signature Phone Numbe Inspe Phone Number <br />INSTRUCTIONS ON BACK <br />[Correct: Incorrect: <br />EXAMPLE <br />1 <br />2 <br />3 <br />62081 <br />�� <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />