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0 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1177592 <br /> CalRecycle181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> r ness Profile Inspection Details <br /> O Inspection Type(Fill one) <br /> bite Suffix: { S Q Routine Q Re-inspection ® Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: 7�K J�y,n, V t el �V���/ Q CHP ® CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S� ecc'o__ Lvw\b <br /> Physical Address <br /> C v •e <br /> U Inspection Date <br /> s �-o c.l�.k_0v1. C °I Z 3 <br /> Time In Time Out <br /> Business Rep Title AM ® AM <br /> Com1 O O O PM 15 Q PM <br /> Q <br /> wai;Cdn ps (-. <br /> 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> o <br /> GPS Latitude ® Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) �p�tiC <br /> n New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> lsed Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder i Other 9 Ocr)r 1 C..`+:S jkjqn v e� <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 <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 EXE C2 <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 /> 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 /> oto Other:§ <br /> Comments R c,(recra` 4r(Dv-n CAA 2 cy e_ eye W:c Ck aLi,'A-4.k.--6 <br /> vCQSyiake� . 9J0 <br /> a<- QHS onC hc��i►��� <br /> Cpv�rcc'tj <br /> �CAA.-S! 1.100 'ms amm e.\e rr skoraoyt �. �c�c1 ' oy��y lntrs ��t lal;��S <br /> 7 Mo waSke -re. k44 GLose- L V. <br /> ection Form Included: Q f � <br /> Comments Included: Q h/ ,��-�y ➢y7 �� ��-y�� <br /> Business Rep's Signature Phone Number nsp tor's Signature Phone Number <br /> �,{ <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X �J E X A M P L E 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />