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Waste Tire Su. vey & Inspection Report 9nspection Report Number ■ <br /> CalRecycle State of California I 1 - 1196264 <br /> CalRecycle 181(Rev.y/10) 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- Q Inspection Type(Fill one) <br /> Site Suffix: ` -( 3 6 0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local CC __ If Referral,choose referral type(Fill one) <br /> Identifier: Xt� �O��v�\ Cf�1M' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 4cros w - uv(�I C.) I. <br /> V Inspection Date <br /> L.o6; CA cK-24X l 7 <br /> Time In Time Out <br /> Business Rep Cr Title n O AM O AM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O <br /> GPS Latitude ® Closed 0 Alt41A 0 Hauler 0��� <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E?(7) n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> f <br /> W <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators a In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments � 1 "� 1 r/ / <br /> Si Wll�' L i�Y1¢- �� No U+a 6,�an k Q� c a o Y 6nq 4C vn 1 <br /> dok-bAtoIns 'P -tkL -1--es0 0- 1611 36 S 0 �# _ <br /> Z ntCOmMCnc� -jkL3 "-�MO A 10136Lf cloaCC� <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> � ��� g� �io� - <br /> Business Rep's Signature hone Number Seco Si nat a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct, (Incorrect: E X A E 11273 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L © ■ <br />