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Waste Tire Su. ./ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 121013 3 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 / ` , - © Inspection Type(Fill one) <br /> Site Suffix: b "� e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: „ Q V'L,n Co�,v Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � Inspected By Inspector <br /> 1?rdo\s:�`� e� civ.�. �p ���p C`4 - 1 � <br /> Physical Address I MATTO <br /> 3m VA. <br /> r c��ov\ Inspection Date x � O 3 <br /> � C �S2lq <br /> Time In Time Out <br /> Business\Rep �1 c�//� wa, gl Title M��K �PM Z V�;C 2 . 1 O 0 AM : 1 - C) a AM <br /> N1�GV1,a2.` VSO� � � � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' b 0 Active Q Passenger 0 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned * OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) Gost <br /> Q New Tire Dealer Q 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 0 Other Lov� o V�$� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 / ITI / 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 EX7J 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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments t <br /> O C41 ��°�-�— <br /> IA <br /> O ito�� ��s �� e� 6r1- <br /> Inspection Form Included: Q Zell / 2 <br /> VVI <br /> Comments Included: 78— - - - -_ ��q^���-v��q <br /> l <br /> usiness Rep's Sign re Phone Number Inspector's Signature Phone Number <br /> �( <br /> X 4 �J <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />