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-:. ::.. . _:. : ._ -_- - .:.-.: :-:: llev,r fiixL._�a ___ �min✓......:...n:.._.... -.-..-_- .... . ........ .._...___._- .-. .....__ _. _ -___.__. <br /> 02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 1 11 - 1176486 <br /> CalRecycle181(Rev.10/10) Survey Form - Page <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A - Survey _ -_-_--— ---- --- <br /> Business Profile Inspection Details <br /> TPID- 1 _ O ` Inspection Type(Fill one) <br /> Site Suffix: ` S 3 I J Is Routine Q Re-inspection Q Referral Q Observation <br /> LocalC ' If Referral,choose referral type(Fill one) <br /> Identifier: JCk1) v 0aOL�' f\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 31 <br /> O <br /> Lwk1�c�� <br /> q Inspection Date <br /> \ I 5 t 1 <br /> 1, s D P ` Time In Time Out <br /> �y0 AM 0 AM <br /> Title <br /> Business Rep ` 3 v 0 & PM kA 5 e PM <br /> Operational StatusTire 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) , O` I$Active S Passenger Is Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive I • Truck <br /> Longitude – Q Planned 10 OTR Q End Use I Q container <br /> — <br /> I Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 <br /> Q Q Other:§ <br /> Comments1 t <br /> St, i j� I s <br /> s� 61 ` <br /> QJ CAS C1 A s <br /> Inspection Form Included: Q / Z o 14 7 Q <br /> 76 <br /> Comments Included: --Business ln____�'s SPhone Number Inspe is Signature Phone Number <br /> 62081 <br /> [Crrect-:INSTRUCTIONS ON BACK ** Incorrect: X ) E X A P L 1 2 3 <br /> Pink Co y:L <br /> White Copy:CalRecycle Yellow Copy:Operator © ■ <br /> ■ <br />