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.R. <br /> 02 Waste Tire Survey & inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecycleCalifornia 181(Rev.10/10) Survey Form - Page 1 11 - 1- 176826 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile flinspection Details <br /> Profile <br /> Type(Fill <br /> Inspection Type(Fill one) <br /> TPID- Routine 0 Re rZiteSuffix: <br /> 4j 4-1 Q_ Routine 0 Re-inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Local <br /> Identifier: /In 6CX./rL 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Ad <br /> Inspection Date W <br /> CA q5-?c')cj Time In Time Out <br /> f AM 0 AM <br /> Business Rep Title 5 PM 1 Z PM <br /> > 0 <br /> fACA.,++ 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) 4& Active Passenger # Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 0 Hauler indoor <br /> GPS <br /> Longitude Latitude 0 0 Inactive X—Truck 0 Container <br /> 0 End-Use <br /> L itude 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 0 Auto Repair <br /> I* 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 0 Notice of Violation 0 Extension <br /> 0 . 0 PRC§42951 Waste Tire Hauler Registration and Transport of Tires compliance Deadline <br /> Tires <br /> 0 STATUS <br /> 01 <br /> Notice Of Violation <br /> Compliance 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 7c ce Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m / m / m <br /> ent, Date <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) C� <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 7 -e <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered 2 <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 0 in Compliance-No Violations <br /> 0 , 0 1 Other:§ <br /> Comments <br /> -------------------------- <br /> r. <br /> d <br /> Inspection Form Included: <br /> C m orm I cl Included: OL <br /> Inspection Form Inclu e : 0 <br /> Comments Included: 0— Is Signature Phone N ml 'nsp s g ature Phone Number <br /> B siness Rep <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: VN E X 2 _3 <br /> ■ <br /> ■ 4P1ink Copy: <br /> White Copy:CalRecycle Yellow Copy:operator <br />