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_..._. ...:....-_ _•___..v o S`...-...._.vv_v._ .� .z ....] _ l.. .__......u v.•. ......... .• . .....v...................... . .._ -.- .._. -• - - - - <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRec <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1196649 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: I 3 �-� 8 - b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `` j If Referral,choose referral type(Fill one) <br /> Identifier: Sct,tn JOG_% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> .)--YS 1— C.��S !✓vim K.�Vicom .L✓LG . q - <br /> Physical Address <br /> r1 Inspection Date l / D 7 13 <br /> l vG Gn qi 5-3-77 Time In Time Out <br /> Business Rep Title / ®AM 1 O AM <br /> ZD JaLvti3 <br /> ScfGI ��/ I t 6 O PM l Z O D *PM <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 /> i Active Q Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O 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 Q Q Notice Of Violation Q Extension <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 /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 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 Q Referred/CalRecycle Enforcement <br /> Lu <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:§ — z <br /> Comments <br /> Clommcn_A. <br /> Inspection Form Included: Q <br /> Comments Included: ` <br /> Business Rep's Signature Phone Number UsSijo/nature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NJ EXAM P L 11213 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy ® ■ <br />