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02 Waste Tire Su. _ay & Inspection Report fspection Report Number ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 - 1176546 <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: .7 f0 - Q ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CiM �pfccin 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business��orrF�Facility Name ' Inspected By / Inspector <br /> Physical lCddre' s <br /> 4 Ll 0 ern'u, <br /> ( A �-S';7,06 Inspection Date ® � <br /> Time In Time Out <br /> Business Rep Title 0 AM r 0 AM <br /> C © * PM © d Q Q ® PM <br /> cs:-r; L am S a-ll C" " 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) i f <br /> WA <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 0 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 /> 0 0 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 EX7) N <br /> a <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 /> 2 <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 0 Other:§ <br /> Comments / `,', ¢ <br /> 1i1J;TY)1/ C'Y1i Sinn '( 61 t„ <br /> i <br /> L-.rGI�Z�7 n�71 <br /> Inspection Form Included: ®uded: 0 <br /> ` .20?-3)-3 7� (Wet) <br /> q�^ Z 3 <br /> LComments Incl <br /> Business Rep's Sign ure Phone Number Inspector's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: E X A M P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E ® ■ <br />