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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226662 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey- — - - - <br /> ---- ---- ----- - - <br /> Business Profile Inspection Details <br /> - - -- <br /> TPID- I_ G Inspection Type(Fill one) <br /> Site Suffix: 1 Vl ' - O Is Routine Q Re-inspection Q Referral Q Observation <br /> Localt If Referral,choose referral type(Fill one) <br /> Identifier: S( � J�rt r.�kI rN (py�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - <br /> Physical Address 3 1 v I �E 'h <br /> �aaR va0 al_rb I,l� G rGIk, ^^�� <br /> Inspection Date p� <br /> � I / J, / , 1 <br /> (`(� (N�c C CA IS337 Time In Time Out <br /> Business Rep Title h0 AM OAM <br /> 3 V <br /> PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , '10- Q Active Q Passenger Q Generator Q Outdoor <br /> D ® Closed Q Altered /V N /A <br /> PS Latitude / Q Hauler Q Indoor <br /> GQ Truck`A <br /> D Q Inactive <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q New Tire Dealer Q Auto Repair <br /> Q 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 __- 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 Manifesting Requirements Date m / m N <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q (Required for NOV or EXT <br /> N <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years c <br /> Q Q Q Referred/CalRecycle Enforcement <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers w <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:§ <br /> Comments _ 6 (� 1 <br /> lU !� 1 <br /> Inspection Form Included: Q l!S"p ' <br /> Comments Included. <br /> - - - � � _�.'Z4Y-ate - �k6 ��-31 � <br /> �Busln s ep's Signature Phone Number Inspe -r's Signature hone Number <br /> -----—----- - -- �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X N_J E X A P IFI 1 2 3 <br /> ■ <br /> ink C py:LE <br /> White Copy:CalRecycle Yellow Copy:Operator P © ■ <br />