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s <br /> 2 Waste Tire Su. .ey & Inspection Report nspection Report Number ■ <br /> ® te of <br /> CalRecycle CaaRecyclelifornia 181(Rev.10/10) I 1 - 1210155 <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- 1 7 _ O 1 Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local `�' If Referral,choose referral type(Fill one) <br /> Identifier: s v% V (3 CtA k3�n CC> VAV Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A � Saw,��b Sd� <br /> Physical Address � q ' Q <br /> CAgS236 Inspection Date � / 3 Q / , 3 <br /> Time In Time Out <br /> Business Rep Titlec 0 AM C 0 AM <br /> I <br /> ' ? J 0 PM 2 J O PM <br /> - <br /> OporaYalal Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fig or*ontly) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 7 0 Active 0 Passenger 0 Generator Q Outdoor <br /> GPS Latitude Q Lamed Q Altered <br /> Q Hauler' 9 Indoor <br /> Ci rwwvve • Truck <br /> Longitude - i C .red OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Go.s-wrrrr Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q ceim:fon Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q &roww 0 Other 60 <br /> Part B - Inspection of Waste Tire Dealer,Generator,Hmuk lr WW 961"se Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesbng Requ.ements Date 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 w 90 (Required for NOV or EXT) <br /> a w+ 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 m <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments <br /> «v\�� 1t�, WCA-S \ 'bNz�" <br /> crn )Ss' <br /> Ck <br /> Inspection Form Included: Q2.0 Cr <br /> Comments Included. Jwdna� /��� )/ <br /> Lv'-Y6v���C7 4 <br /> Business Rep's Signature Phone Number Ins ec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:6 Incorrect: X � IEIXIAIMIPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />