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:i:�tii'� .�.V:--:= �:titi.:ff�b:� :;.�v,::.Y.';:52:�:1;.ti::,:ii��,:".+�3e+._..'-':.'::s'=.;=:uir.:.sS��;�-��___ :i.•.'.a �cv=�:�tia>iiiv:_ _ .:s:�:.i_w_:.w.�._...-u-.�u-.au1.��.-_a_�-. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1230197 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> )art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � Inspection Type(Fill one) <br /> � <br /> Site Suffix: D * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: dpQ��cc.i» 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Avo 1(-h 66u "I Inspected By Inspector <br /> Physical dre�'s o 3 7 - / o ( S"A&-o7x,-ik-vL,,4 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title `' 0 AM AM <br /> f✓ / 0 PM ® ® 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude , Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR End-Use • Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 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 /> 0 0 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 /> 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 /> w <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 <br /> in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments ��� � �f►.=,o-tTS E4rt �1 o�c�c� c�..r.f 't�'•f �'+��-cam� =-�J� i�s�traC <br /> �u <br /> t4, �"L l`'`z'.c�+'��� t/Z <br /> G=r/�w•P Jcz-�e �r%/� /'-Grp r'td✓. � to 4-u'."7``�-f PSC ih� f/'G� � .�—�-`°�- <br /> .�h ce u•�".-•�a �ry a-rc yup.:icy-F•�`f on � �� �°s wr . /(/v ver�<•�rS�•,,.—g <br /> Inspection Form Included0 <br /> Comments Included: 0 <br /> Business"Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM E I 1 12 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy.L �� ■ <br />