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03 Waste Tire S.irvey & Inspection Report Inspection Report Number ■ <br /> CalRecycle CalStte of Recyclelifornia 181(Rev.10/10) I1 - 1176815 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A- Survey -__--___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � I - � � Inspection Type(Fill one) <br /> � � <br /> Site Suffix: `6 I Q Routine 41 Re-inspection Q Referral Q Observation <br /> Local e--:- If Referral,choose referral type(Fill one) <br /> Identifier: ISW) �� ��� �U(��' Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> F i g �r w ,� 3 g - I o &n <br /> Physical Address J <br /> aco\wn Ave, <br /> Inspection Date <br /> 5��� <br /> Sero coo r� CA VVV l <br /> Time In Time Out <br /> Business Rep Title O AM 3 O AM <br /> 01 b Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 1 <br /> ® Active 0 Passenger 0 Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 46 Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> 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 /> 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 EXE N <br /> a <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 /> f <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 ®In Compliance-No Violations o <br /> Q Q Other: <br /> Comments �n'�I n <br /> A >14)N t ky.s 0,oic <br /> 0 wls' \4'10��InnL VY� 6K' <br /> Inspection Form Included: Q \ '1 1 j,� <br /> Comments Included: Q --- ��—L�- - �rsSiqnature �, 1 <br /> vq� <br /> Business Rep's Signature Phone Number Insp - Phone Number <br /> �( <br /> INSTRUCTIONS ON BACK [Correct-0 Incorrect: � � VJ I E I X1 A P L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :L © ■ <br />