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Waste Tire Su, vey & Inspection Repori Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1226516 <br /> lR <br /> CalRecycle 181(Rev.10/70) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(Caecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ' yn_ (� (1 g 3 l a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: so-y" '-Scx�c --- �I✓VL�Z] Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U e---1 ' <br /> Physical Address t Q �- yy��;J�` <br /> Com M r c a✓ .st-. <br /> CA q5oa06 <br /> Inspection Date !) 0 / P � L 1 <br /> Time In Time OCu't 1 <br /> Title i AM ®AM <br /> Business Rep O O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 1 / 70 <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 C (Required for NOV or EX7 N <br /> CR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days r <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 O In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments <br /> s <br /> r <br /> Inspection Form Included: <br /> Comments Included: ® n �-� Ph ) F�73 <br /> usiness Rep's Signature one NO, ber or' Phone Number <br /> -- _ I s Ignature 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ( �w EXAM L 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy L © ■ <br />