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03 Waste Tire Survey & Inspection Report inspection Report Number <br /> CalRecycle State of California I 1 - 12 2 6 6 0 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE ®R BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / I spection Typeill one) <br /> Site Suffix: OnRoutine ORe-inspection Q Referral Q <br /> Observation <br /> Local l ( If Referral,choose referral type(Fill one) <br /> Identifier. Sin �1 u'n ` ��� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> A civ a l b 710(e s 3 <br /> Physical Address �S C <br /> Inspection Date <br /> �c�fon C� QSaos <br /> Time In Time Out <br /> Business Rep Title Q O PM AM <br /> 1 l 5 0 PM <br /> --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) h (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' v <br /> If Active ® Passenger ® Generator (f Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® 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 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <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 <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 a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 'z <br /> 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:§ 4 }, z <br /> Comments (4)v4',1.L ��S9 t- �lta. II n 1 d^ M. OA 1)n1.$ 1+_0 <br /> L 5 n o�cd <br /> Inspection Form Included: Q (� q <br /> Comments Included: <br /> Busines ep's Sign ture Ph In <br /> ne Number sp toy's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct; Incorrect: NJ E X A M 11213 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop L © ■ <br />