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JIM.... <br /> 'R _ 0 <br /> & 0 , N N-1 _-�:; A -i�,*��z-NQ�'�:x�%"rl�,,�uti-x-�z�z,*- <br /> nk <br /> M <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 1242240 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey ___ <br /> Business Profile Inspection Details <br /> TPID- '2 C) inspection Type(Fill one) <br /> Site Suffix: 7 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: OA Y\ (0\3r.��j 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> '3, 9 - \ C> k Ary 7 k3 <br /> Physical Address <br /> Inspection Date O q <br /> Time In <br /> ime In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> k : 95 5 0 PM 0 P <br /> r ti <br /> \z yo�nv--\ I Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> 0 0 inactive 18 Truck 0 End-use ® Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 07New Tire Dealer 0 Auto Repair 0 Trucking Fleet Government <br /> 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 / m / <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle V) <br /> (Required for NOV or EXT) T <br /> c� <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> 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 <br /> Other:§ <br /> 1 1 1 <br /> Comments e- <br /> r <br /> lzl� <br /> Inspection Form Included: <br /> Comments Included: B si ss ep's Signature Phone Number Inspect is Signature Phone Number <br /> Ct. X 62081 <br /> S <br /> INSTRUCTIONS ON BA KFCr7rejc:t-:* :1n correct: X E I X I A I M I P I L I E <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Copy:LEA <br />