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- --------- ............ ........... . <br /> V'. ....... ... ........... <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of <br /> Cal Recycle calRecycleCalifornia 181(Rev.10/10) 1 - 1177618 <br /> Dept.of.Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: Q t t 4 l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address MW14SOLA <br /> Inspection Date q / '-7- '2 / 1 3 <br /> CA Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 57- 0 PM ®PMAyftw--)o &w o-,s <br /> 14 111 .4 4zaCitu{cu <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 /> ® Active 0 Passenger I& Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 Inactive 0 Truck 0 Hauler 0 indoor <br /> Longitude 0 Planned OT Vj 0 End-Use 0 container <br /> _ <br /> or F&9 F r I <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 CLln"r, <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A** HAULING AND MANIFEST REQUIREMENTS ' 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datemm 04 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 9 <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators *In compliance-No Violations <br /> .0 0 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> z _7 <br /> Comments Included: Business Rep's Signature Phone Number— In nature Phone Number <br /> F_ _4-1 E. 1 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X A L E 1 2 3 I ,�j 1 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® ■ <br />