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02 Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California <br /> CalRecycle 161(Rev.10/10) Survey Form - Page 1 I1 - 1230343 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 0 � � � � � � _ � I lOOInspection Type(Fill one) O O <br /> Site Suffix: Routine Re-inspection Referral Observation <br /> Local l- If Referral,choose referral type(Fill one) <br /> Identifier: : G)40 v j ,� �{�Tln 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address 3 9 <br /> It al <br /> Inspection Date 3 v l s <br /> Time In Time Out <br /> Business Rep Title I <br /> 1AI�1, � O 0 PM � 1 J 0 O PM <br /> e.!'" <br /> -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 3 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 0 -- 0 Notice Of Violation 0 Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <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 EXT) 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 /> 0 in Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments t&JeA(c,'n594 bon U jj' o:eA S d 4?e q N/` t <br /> No \140 'O -u (if Aic,lns 4 LQnC,Qrn- <br /> Inspection Form Included: 0 <br /> Comments Included: ��— <br /> B in ss Rep's Signature Phone Number Insp or's Signature Phone Number <br /> ,�j� 62081 <br /> INSTRUCTIONS N BACK Correct:40 Incorre . � 7d `J E X A L 1 111 <br /> 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C py: <br />