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--------------Awk,--------- <br /> ■ <br /> Oa Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRecycle State of California 10/10) - Page 1 11 -1176357 <br /> CalRecycle 181(Rev. (CalRecycle) Survey Form <br /> Dept.of Resources Recycling and Recovery(Cal BLUE OR BLACK INK PEN <br /> Part A- Sqrvpy— <br /> -----.--- <br /> inspection Details <br /> a' <br /> Business Profile <br /> Inspection Type(Fill one) <br /> OL C <br /> 3 e <br /> TPiD- 0 Referral 0 Observation <br /> S ffix <br /> Routine 0 Re-inspection <br /> Zite Suffix: 3 <br /> If Referral,choose referral type(Fill one) <br /> r Vj <br /> Local plaint 0 Educational Visit 0 Other <br /> Identifier: !bCXV1 0 CHP 0 CalRecycle 0 COrn Inspector <br /> Business or Facility Name Inspected By <br /> M <br /> Physical Address A16�o <br /> Inspection Date 0 :F / t I <br /> CA 45`� 0 Time 114 Time Out 0 AM <br /> 0 AM M <br /> Business Rep Title PM OPM <br /> Operational Status TTireType Business Role Storage Type <br /> Oc L 1`1 '110 0 1 (Fill all that apply) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) 'Ply) <br /> Active <br /> 'v <br /> Tire Count (Whole/PTE) Q Active 0 Passenger Generator 0 outdoor <br /> 0 VIA- <br /> 0 closed 0 Altered 0 Business Role <br /> indoor <br /> GPS 0 Latitude 0 inactive 0 Truck 0 End-Use0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer <br /> 0 Used Tire Dealer 0 Auto Body 0Car Dealer 0 Collection 0 Crumb Rubber ol <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 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 _Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> THA 0 Notice of Violation 0 Extension <br /> Compliance Deadline <br /> 0 PRC <br /> Ints <br /> RC§4' <br /> 0 PRC§4. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle Requirements Datem / m / m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements <br /> 00 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle CP <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 1 CC Trip Logs for 3 years <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive0 Referred/CalRecycle Enforcement <br /> for Registered Waste Tire Haulers 2 <br /> 0 0 14 CCR§18460.2-Manifest System RequirementsLU <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 0 In Compliance-No Violations <br /> 0 0 Other:§ <br /> [Comments <br /> II Inspection Form Included: 0 <br /> Comments Included: Ins ct r' gn ture Phone Number <br /> a ure Phone N 62081 <br /> 1 3 <br /> Correct:)INSTRUCTIONS ON BACK Correct:log Incorrect- E X A M <br /> _r <br /> White Copy:CalRecycle Yellow Copy:operator Pink Cop <br />