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03 Waste Tire , vey & Inspection Repur Inspection Report Number ■ <br /> CalRecycle State of cle181(R 11 - 1176840 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <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- a Inspection Type(Fill one) <br /> Site Suffix: ` Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local r1' If Referral,choose referral type(Fill one) <br /> Identifier: Sties VUalJAA n C0�►� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name rInspected By Inspector <br /> \A_0\' * c� 11 0 tn, _ <br /> Physical Address ` O <br /> 1 <br /> \_� Inspection Date � / D <br /> S�Ut�"l�0n G� <br /> Time In Time Out <br /> Business Rep Title 0 AM e 0 AM <br /> ' PM O 7 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) 3 q <br /> ® Active Q Passenger ® Generator 0 Outdoor <br /> -- O <br /> Q Closed 0 Altered Q Hauler Indoor <br /> G PS Latitude <br /> O Q Inactive 9 Truck <br /> Longitude - Q Planned ® QTR Q End-Use Container <br /> Business Type(Fill all that apply) <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 a Hauler Q Agriculture Q Shredder O Other 11t Q� yu�_ 1CQ(1�Q� <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS— - <br /> V A HAULING AND MANIFEST REQUIREMENTS ®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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M mo (z I ,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 EX N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Referred/CalRecycle Enforcement <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <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 Q In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �,DUI'4irw1�L. C, fQ, i f�S�� hLae C4,OA lyv, <br /> Inspection Form Included: Q <br /> Comments Included: • (/J (i <br /> bliffiess Rep's Signature Phone Number Insp or's Signature Phone Number <br /> n �{ 62081 <br /> INSTRUCTIONS ON ACK Correct: Incorrect: X �N �J EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br /> vvnne uupy.%,m mD ..1— .-Py. , . ...-__r, _.. <br />