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------------------ <br /> ................ ------ <br /> .......... ---------------_ <br /> ......... ............. ............ <br /> ... ......... <br /> 03 Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle calRecycle 181(Rev.10/10) 11 - 1177891 <br /> Dept.of Resources Recycling and Recovery(calRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- LA inspection Type(Fill one) <br /> Site Suffix: J 1 41 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San ObUq 1A1 f-1, C01A 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> ) <br /> Physical Address 0 <br /> Inspection Date <br /> 11 <br /> ( A � 0 / 0- <br /> Time In Time Out <br /> Business Rep Title * AM 0 *AM <br /> lb F 0 PM 0 PM <br /> 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) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 Inactive 41 Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ID 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 m C11 <br /> C� <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 4 <br /> In <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXET <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 ID In Compliance-No Violations <br /> .0 0 Other:§ <br /> commi!!1111t:!; Ins S1, <br /> C-bn (co <br /> Inspection Form Included- 0 20 <br /> 7L <br /> V7 0 4� <br /> t4�) <br /> Comments Included:11* <br /> Business Rep's Signat Phone Number InsprornsSignature Phone Number <br /> 62081 <br /> Correct: Incorrect: <br /> INSTRUCTIONS ON BACC <br /> K Z\ IEIXIAIM P 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Copy:I <br />