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r <br /> � <br /> w� Waste Tire S'.. vey & Inspection Repor� Inspection Report Number <br /> CalRecycle State of cle 181(R I 1 - 1210545 <br /> CalRecycle181(Rev.y(Ca Sur vey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V � Y Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Tplp ' � ` � � � � - O � Inspection Type(Fill one) <br /> Site Suffix: * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: (;ol� �C♦Q V r I 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 7 Vg �) Z�CaS�`2 <br /> SInspection Date � / � 3 / 1 3 <br /> �rc3c�n-�v� CA _IS2ls <br /> Time In Time Out <br /> Business Rep Title 0 40 AM ®AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 12 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 2S 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> �PS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned * OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) ;!0- � <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 Q Extension <br /> 0 0 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 <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 EXn <br /> 0 <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments <br /> y���..v� �,�,�r�S�Q��K'� 1�r�Sp2�•'Raa'Y\ (=�-W-,-�Y�. `�n��S C`br�R-- O�C�— <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: q �jEjXjAjMjPjLjEj Ill2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />