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OZ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 1 - 1226669 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- ` Q - D I Inspection Type(Fill one) <br /> Site Suffix: I I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: cc', L' 1,^ (OL4 nim Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> � (M C- Tau r,� f wf ( D ) ��co v <br /> Physical Address <br /> IM6 S , W11.5t)rn <br /> 1^ Q S Inspection Date ' l <br /> L�'r/1 bn �n l�� Time In Time Out l <br /> Business Rep Title O AM S O AM <br /> D 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> r <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J <br /> � ® Active Q Passenger ® Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 Dismantler Q Tire Derived Fuel <br /> 46 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> v <br /> N <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> W <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ L I <br /> Comments 9 u � ��G17"1 .� �� 1 I r (� 4 i — <br /> � oAS �i" <br /> N 0 V a[AR nn:s <br /> Inspection Form Included: _ <br /> Ll - - - �ac�°l-1 �"317 <br /> Comments Included: ® - -— — -- J - <br /> Business Reps Signature o e Number Insp for s Signature Phone Number <br /> I� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 'zX � �/ E X A M L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.LE © ■ <br />