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02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle I 1 - 1210595 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <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: li, Li 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` -- If Referral,choose referral type(Fill one) <br /> Identifier: -✓� �vl� � � 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name LL Inspected By Inspector <br /> Ec)wcw-c L,-- cz rem-, 5 C. L O t /�-f�l <br /> Physical Address L) <br /> Inspection Date / / / <br /> cA 17s3 <br /> Time In Time Out <br /> Business Rep Title j L f ®AM ! ( PM <br /> � �Utv��,✓ !�G�t.'Lam" [ O 0 O PM <br /> 451-me-kl 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 ®Generator 0 Outdoor <br /> O ® Closed 0 Altered G'r 14 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <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 a k <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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> N <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <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 /> Inspection Form Included: 0 / �- 2-C, <br /> Comments Included: 7 �l6p T67 <br /> ness Rep's Sign re hone Number I pe for ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correet:-* Incorrect: NJ EXAM L E 1 Z 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA, © ■ <br />