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':_:-- rrJ,`�/A!<1�15G7I,Er/%li�fff.{ 4 f--.-f.1iref��i.�.: . -i:f :w d : _.•: ::t idldtir.:�ei}u:irif r i.:,:..:. r.._ _..._ _:s•.- -._ <br />Waste Tire Survey & Inspection Report 'Inspection Report Number <br />CalRecycle State of California 11 -1226683 <br />CalRecycle 181 (Rev. 10/10) Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) RI 11F OR BLACK INK PEN <br />art A - Survey_- - - -- <br />-- --------- <br />Business Profile <br />Inspection Details <br />Inspection Type (Fill one) <br />TPID - _ <br />Site•Suffix: 6 0 <br />®Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local ` <br />\��.1������ <br />Identifier: <br />Business or Facility Name <br />Inspected By Inspector <br />L- s cc -'J ccv, �vvl G✓ �G Yl. 6S <br />3 c� - & <br />Physical Address <br />vcv5 <br />Inspection Date <br />CAC�� <br />LSC l� �`� `-'�`'� <br />Time In Time Out <br />Business Rep Title <br />1 O 4 AM AM <br />} <br />PM �� PM <br />I �j <br />�."fc,Ave c:k�n� r c.�! c "� e�� <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />Tire Count (Whole/PTE) l <br />® Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />® Outdoor <br />Q Indoor <br />GPS Latitude <br />Q Inactive <br />Q Truck <br />� <br />Longitude - <br />Q Planned <br />® OTR <br />Q End -Use <br />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 ® Other �,r,;,yj,U <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS _ <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m// m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />(Required for NOV or EXE <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />1010 <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />Comments Included: a <br />Busi s Rep's Signa ure Phone Number % Ins e n re Phone Number <br />-- <br />-- --- 62081 <br />INSTRUCTIONS ON BACK Correct:* Incorrect: M 64) v)E X A IVC 1 2 3 . <br />\�Ihiio rinnv r'. 1PR 1CIA Yellow Coov: Operator Pink Copy. <br />N <br />N <br />CV <br />a <br />Lo <br />0 <br />i <br />Lu <br />Lu <br />