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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRec cle State of California — <br /> Y CalRecycle 181(Rev. (Cal Survey Form - Page 1 11 1230100 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 G 1' Inspection Type(Fill one) <br /> Site Suffix: 1* Routine Q Re inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: �a,� ' OCxLAIAI n cou.'l z Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C(cxik�(n G lu.,e "C� DoawS 3 <br /> Physical Address 1 V CS(0- TO <br /> CnuL� l�.�r or- <br /> �cGwJ <br /> CA %371 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> �L C7 5 ® PM �" 3 PM <br /> (Z u(_� Su 4s Q�fN-i4r'U_ er <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q lG,enerator Q Outdoor <br /> Latitude O ® Closed Q A!ered"yy1 Q H eA O d A <br /> GPS <br /> or <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> 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 Q Other N I A <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 Notice Of Violation Q Extension <br /> Q Q <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 /> 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 <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 <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> f <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 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 /> v'S 00VCZK= ( � �\c����iws � (Meus Of Wnc-ern <br /> &a, Ink* vr". W AI- -�i-5_ �L%c\l;� w� c� c,J�, -`1�-c�¢r <br /> �n�1t$Itu. Cta��-s4�o_ <br /> Inspection Form Included: Q .),Oct 647 Cpy� <br /> LILA <br /> Comments Included: yri <br /> Q � � <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK FCorrect.0 Incorrect: X q EXAM E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® ■ <br />