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Waste Tirerirvey p& Inspection Repsolnspection Report Number ■ <br /> � <br /> CalRecycle State of California 11 - 1176370 <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' 3 $ 41 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: dCO Al f u(, Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or FacilityNameInspected By Inspector <br /> e� n oz <br /> Physical Address <br /> Inspection Date 7 / 1 <br /> Time In Time Out <br /> Business Rep (`W I1�� Title O AM 0 O AM <br /> 1SI Ely-, 1 `4./ 0 / 41 PM a V ® PM <br /> O Operational Status Tire Type Busi�Rey) Storage Type <br /> 7 (Fill one only) (Fill all that apply) (Fill aFill all that apply) <br /> Tire Count(Whole/PTE) , <br /> ® Active Q Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive • 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 11,- r II- <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • Other ((��((���a1 tX.� 1 1A01A(X(,"fVi n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m N <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 N <br /> U) <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 /> Lu <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 &n Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments YaO \ �� J� \(�S 1 f•1 l <br /> (0) Da w;D 0 u5 n 0- 'j = <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> - -- �l 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E © ■ <br />