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03 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of Califor * <br /> galRecycle . .He <br /> Survey CalRecycle 181(Rev.10/10) Page 1 11 1242388 <br /> Dept.of Resources Recycling and.Recovery(CalRecycle) <br /> ey Form <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z <br /> Inspection Type(Fill one) <br /> Site Suffix: 0 Routine le Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address A-4v <br /> Inspection Date 0 -3 / -Z � <br /> L.&" C) Time In Time Out <br /> Business Rep Title C) 0 AM I <br /> ki 5 0 AM <br /> PM CFPM <br /> Operational Status Tire Type Business Role— Storage Type <br /> Tire Count (Whole/PTE) 2 l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive Truck 0 Hauler 0 Indoor <br /> Longitude 0 Planned OTR 0 End-Use 0 container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreade'r 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 I 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 Date 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 EXEN <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 /> 2 <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 <br /> is In Compliance- No Violations <br /> 0 0 Other:§ <br /> Comments <br /> )x\ <br /> f Mo \'m-t�XOX-%tMz) es (MAcrsn <br /> N N <br /> V <br /> Inspection Form Included: <br /> ZO 9 -2�49 329 <br /> Comments Included: 0 <br /> Business Re0eignature Phone Number Inspect6r's Sign-at Phone Number;r _ _ <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: kcv:1 JEJXJAJ E1 1112131 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink CoM <br />