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Waste Tire SL_ ,iey & Inspection Repor. Inspection ReportN//umber <br /> CalRecycle State of California 1 1 1 1 7 6 ' r1' 3 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK I N K P EN <br /> Part A-Survey -- -- - - - — <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: / G C i 3 3 G I ! Routine Q Re-inspection Q Referral Q Observation <br /> LocalC If Referral,choose referral type(Fill one) <br /> Identifier: savi � Um (&� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /� Inspected By Inspector f_ j <br /> I Ad0,Y1� AA0%-, <br /> (Cel K ei <br /> Physlcad'ress <br /> r10 - -- - <br /> Inspection Date <br /> .r1 <br /> n ( }L <br /> �� Time In Time Out <br /> Business Rep TitleI � � 0 FM � �I 57� AM <br /> PM <br /> A� 1 <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) , p� ® i Active 49 Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q 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 /> 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 B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice of Violation Q Extension <br /> Q Q 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 /> N <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q (Required for NOV or EX7 <br /> N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 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 Q Other:§ <br /> Comments <br /> Inspection Form Included: Q <br /> 2--� Zoe `13 6 -1 la_2 6�� <br /> Comments Included:. <br /> Business Rep's Signature Phone Number In a gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co :LE © <br /> ■ <br />