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Waste Tire Survey & Inspection Report Inspection Report <br /> �Number ■ <br /> Cal Recycle <br /> State of California _ 11 I 6 { 8 1 1 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 t�J J �+ lfi <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- Inspection Type(Fill one) <br /> Site Suffix: 3 LJ � U � Or v l 0 Routine * 0 Re-inspection 0 Referral 0 Observation <br /> Local ]_ If Referral,choose referral type(Fill one) <br /> Identifier: L-)Cxy\ : C$"i1-W-\ C'C.'✓L1 CJ) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name r' I Inspected By Inspector <br /> Physical Address 1 V , l r-MK 661 . <br /> Inspection Date / t <'� l 1 I <br /> l <br /> Time In Time Out <br /> Business Rep` Title O AM O AM <br /> PM PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) !� C; <br /> ® Active 0 Passenger ® Generator 0 Outdoor <br /> O <br /> GPS Latitude 0 Closed 0 Altered 0 Hauler ® 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 /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body iiD 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> - — - 0 Notice Of Violation 0 Extension <br /> 0 0 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 / 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 EXT) — N <br /> n <br /> 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 /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 40 in Compliance-No Violations o <br /> 0 0 Other:§ <br /> CommentsJ/ <br /> [� <br /> U <br /> Inspection Form Included: 0I <br /> -%Z0 .b _ z -�6a g6-7.�5 <br /> Comments Included: <br /> Bus eK Correct:ss ep's Signature Phone Number I pe o s Si Phone Number <br /> ure <br /> i— -_ X 62081 <br /> INSTRUCTIONS ON BACIncorrect: EXAM E 1 3 ■ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: <br />