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02 Waste Tire Survey & Inspection Report Inspection Report Numberte of <br /> ■ <br /> CalRecycle st- cyclei'fornia 181(Rev.10/10) - 1177951 <br />' Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 <br /> i Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> oSite Suffix: 1 �( _ ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _�C'Y\_ UC.t.0"1'y\_ 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r Inspected By Inspector <br /> A,t-- uti 1,-.<, s--JG <br /> Physical Address <br /> C� lV C-0 ' ) <br /> ( Inspection Date C2 <br /> / a / <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> PM C , ' C Q PM <br /> L��o�c1�t�0 Je>1,�INr-�. �m� ✓ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O0 Closed 0 Altered <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> Isel <br /> Inspection Form Included: 0 /� <br /> Comments Included: <br /> usiness ReVs Signature Phone Number I s e tgn ture Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: EJXW i 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y.L <br />