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if % <br /> Waste Tire Su' <br /> . ,,ey & Inspection Report nspection Report Number <br /> CalRecycle State of CalRecycle <br /> 181(Rev. <br /> R I 1 - 121012 2 <br /> Caycling let8l cover Cal 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- 3 v 0 Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 ( If Referral,choose referral type(Fill one) <br /> Identifier. �l n J(� t,�t '1 l l� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phys'lcd <br /> Oq �sU SyDrn S Q <br /> J l S CIO`s" b <br /> boa .Sulk i V ur i(P, <br /> �J,{1r -- <br /> S 1 O&�V'^n �1 IaS Z(7 S Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM !, O AM <br /> N\ c(,��U M C n(J�\LI(�1 (�1 L1 r111 Qj- ' l l Q PM ' 2 v O 0 PM <br /> - — - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' a Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 Q 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 <br /> 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 /> 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 O 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 In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments n5p9a Uzn' AivNe:®n <br /> \hC� •b 4V ern- <br /> LdPIT <br /> Inspection Form Included: 4in <br /> �A�'y_� ��Comments Included: ,"M' > Uon 0 1% <br /> p's Signature Phone Number Insp�r'signaturne hone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: Xj� VIIEIXIAI L 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L ® ■ <br />