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W �..... -•- - ::i:- M +1�'{+il�`t.ti).Ys�t3i� -�: :� <br />��3A7 \ • rjSh' -- ^_tiav` 1 ".ate s. `Fi -:3�__ 7a:J�as�o.�nu.::. tis --s <br />02 Waste Tire Survey & Inspection Report Inspection Report Number <br />State of <br />CalRecycle CalRecyclel1ia 181n(Rev.10/10) - Page 1 I1 - 1242247 <br />Dept. of Resources Recycling and Recovery (CalRecycle) Survey Form g <br />BLUE OR BLACK INK PEN <br />Part A - Survey <br />Business Profile <br />inspection Details <br />TPID -` <br />Site Suffix: , -7 O <br />Inspection Type (Fill one) <br />Is Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br />Local <br />Identifier: Saw, �-r Z <br />w v�0 <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />Inspection Date � 8 � ` � � I `► <br />c� <br />CN <br />Time In Time Out <br />Business Rep Title <br />Q AM <br />• PM 0 AM <br />t Q PM <br />n <br />J 0.wr2-5 V� <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) <br />Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />S Generator <br />0 Hauler <br />0 Outdoor <br />,Indoor <br />GPS Latitude <br />0 Inactive <br />0 Truck <br />0 <br />Longitude - <br />0 Planned <br />0 OTR <br />End -Use <br />Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS 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 <br />0 • 14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />(Required for NOV or EXT) <br />O 0 14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers 0 Referred / CalRecycle Enforcement <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 .In Compliance - No Violations <br />0 0 Other: § <br />t a <br />FCom�m� <br />Q.. ���c7W�V'C �►��5 1f� � <br />Inspection Form Included: 0 <br />.7c1 60 2 <br />t �Q/ <br />Comments Included: <br />Busines Rep's Si tur _ Phone Number Inspec is Signature Phone Number <br />62081 <br />INSTRUCTIONS ON BACK Correct: 0 Incorrect: m� EXAM P L E 1 2 3 <br />Whites Cnnv: CalRecvcle Yellow Copy: Operator Pink Copy: LEA <br />Lu <br />Lu <br />z <br />0 <br />I <br />