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® 2 Waste Tire Survey & Inspection Report Inspection Report Number <br /> cal Recycle State of California r �➢ ( E <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 11 [� <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> -- - <br /> iness Profile Inspection Details <br /> t PID- Inspection Type(Fill one) <br /> Site Suffix: ` J �) 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /, If Referral,choose referral type(Fill one) <br /> Identifier: sc �Cj(',L� �/�� �CJI/V�i{Z� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> �GLV� ��.`n�fl(] p'Cta ,�fl �7 l f �G�t�G TrC�1'►�L W( <br /> Physical Address <br /> OCAS C4-0_�)� .'()r- <br /> `J �,n Inspection Date / C) Z_ / 1 <br /> Time In Time Out <br /> Business Rep Titlei O AM / O AM <br /> r 6 ID PM -3 v ® PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ,2, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0Pass nger a Generator 0 Outdoor <br /> O Closed Altered /v IA <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O o Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 GJ YlCn.�� <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 /> O O <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 M / m / m <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 EXE N <br /> I <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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> O 0 1Other:§ <br /> Comments <br /> r <br /> f > <br /> ispection Form Included: D <br /> 4j 4 Zq'-- <br /> Comments Included: 0I-Z&Y- 7_3 <br /> Business Rep's Signature Phone Number 1 s 's ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X (�) NJ I I E I X A P I L I E 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />