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OZ Waste Tire Sul _ 43fy & Inspection Report spection Report Number ■ <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10110) Survey Form - Page 1 I 1 -1176463 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: a 5 Z 9 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local // � If Referral,choose referral type(Fill one) <br /> Identifier: �C�yL � ,�»� "L Y1.��f Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> 04t-'A ,rc" p ,i� l}r��wu ►'� S 9 - At 6�o i�- �tir►11o�( <br /> Physical Address <br /> Inspection Date �2 1 ) <br /> CA g6376 l l <br /> Time In Time Out <br /> Business Rep Title <br /> O'AMAM <br /> 1 1 00 PM 0 J ® PM <br /> �►1�/\, G�1 <br /> 17-1 G` \fir 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 /> ® Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler . Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ®OTR Q End-Use Q Container <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 Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle co <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <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 /> 2 <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 <br /> Inspection Form Included: Q <br /> Comments Included: ®- — _-- `��3310 � <br /> Bus ss Rep's Signa r Phone Number I s ect r' S' nature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [CorrectI* Incorrect-_X � E A 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y:LE <br />