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s-:_i2-=i-.--- .]1 �fC{-:._...w_•_`-----�----.ad.......moi':....t:�:...:rs�:__:a_ stv_r...-_ -.....-.,.r.__..,__,__.._. ,�..._._._"'--- --- --:.-._.-. ------ --- -__.. - -- -- - <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 I1 1196396 <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: 0 5 ` ' 3 I '9 Routine Q Re-inspection Q Referral Q Observation <br /> Local �11 J If Referral,choose referral type(Fill one) <br /> Identifier: S0�(� J 0 ci tA I 1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> X521 �Ac �Tic. Ave, . -- - — <br /> /; Inspection Date / 1 / 1 3 <br /> Time In Time Out <br /> Business Rep Title ,l O AMO AM <br /> ® PM � 0 � 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) �- d <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> - O Q Closed Q Altered <br /> GpS Latitude Q Hauler Q 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 I' Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> — <br /> 0 <br /> 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ (Required for NOV or EX7) <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 ��5�� lfcJ �J�W1e, (AOA +�t" N <br /> 1 1_ <br /> 01 4&S -n u rn <br /> Inspection Form Included: Q <br /> Comments included- <br /> Bus! ep's Signature one Number Inspe is Sig ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: E X A M P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink op • A ® 0 <br />