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0 0".&" 9mk6ag�.•.�i.:;3 . q 4 kkunv-...�- -- . <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle181(Rev.10/10 c Page 1 11 - <br /> ) Survey Form 1245250 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- e Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 0 <br /> va. Inspection Date <br /> Time In Time Out <br /> Business Rep Title 0 AMj 0 AM <br /> z : * _� 41 <br /> PM 40 PM <br /> rhitha-elL- ov� own� <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count h I o e/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger A Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Lati ude 0 Hauler 0 Indoor <br /> 0 0 inactive 0 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 4j 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 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 EXT) <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 EnforcementLu <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 in Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> 14 Cal-d <br /> Inspection Form Included: 0 <br /> Comments Included:11110 4�11 cog <br /> Business Rep's Signature Phone Number Inspector's Signa Phone Number <br /> INSTRUCTIONS ON BACK �Correct: Incorrect: X 1 L JEJ 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />