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v..s�ravr_x•._...•_.____cv_a .v:r:::o..c_v_.:_u:-._::.__�:___ -------- --- _ ._.___. ----- _.. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 1 1196642 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: 1 3 3 3 -7 ? 02 I Q Routine Re-inspection Q Referral Q Observation <br /> LocalC _� If Referral,choose referral type(Fill one) <br /> Identifier: �Gr✓L `X�t/-_✓-. CO(Nv Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address _7 <br /> Inspection Date <br /> cwt L i C� �s3a p1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' D O e PM S S ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(V1lhole ' ' , S ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed ® Altered <br /> GPS Latitude Q Hauler Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR End-Use ® Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer • Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 1* 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 ENFO CEMENT STATUS <br /> V A 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 Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / Ffl <br /> / m <br /> Q Q 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 /> a <br /> N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> W <br /> Q Q 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 1 Q Other:§ Ia <br /> Comments <br /> Inspection Form Included: Q 7 <br /> Comments Included: <br /> Au's(rn s Signature Ahone Number p cto I ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X qf <br /> EXAM L 1 2 3 s2081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop ® ■ <br />