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03 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle1(State of CaliforniaCel1I.1 - 1226680 <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 /> - <br /> ---------------------- <br /> Business Profile Inspection Details - <br /> TPID- �7 u Inspection Type(Fill one) <br /> Site Suffix: 3 7 G L 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier. SG��~�� �v►'L / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Ot�L 9E-_xQre_� � ) <br /> Physical Address - 112l� <br /> 393E Pe►n� 1 C�c 6�C �0 <br /> Inspection Date ( r. <br /> Q C�+CVN cA g221,,,5- Time In Time Out <br /> Business Rep Title AM <br /> j � AM (� <br /> x' ! Q PM (.J 1 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) <br /> ® Active ® Passenger (�Generator Q Outdocr <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> o Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> QNew ire Dealer Q Auto Repair ® 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 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§ (Required for NOV or EXT) N <br /> 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2 Q Referred/CalRecycle Enforcement <br /> Manifest System Requirements for Registered Waste Tire Haulers 2 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ — <br /> 6 <br /> Comments <br /> crij-IiL:�A <br /> Inspection Form Included: Q 2 <br /> -;zpZ-'Srd f` f7 <br /> Comments Included: <br /> Bu s R nature Phone Number e r S' n ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A M P E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:operator Pink CopL �� g <br /> ■ <br />