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Waste Tire Survey & Inspection Report thspection Report Number <br /> CalRecycle <br /> State of California 11 -1176583 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(calRecycle) Survey Form - Page BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> inspection Type(Fill one) <br /> 7 ton <br /> TPID- 0 6 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Site Suffix: <br /> If <br /> n_f"r <br /> _ rl.. , <br /> Local if Referral,choose referral type(Fill one) Visit 0 Other <br /> Identifier: 1�� 0 CHP 0 CalRecycle 0 Complaint 0 Educational <br /> Business or Facility Narl`16' Inspected By Inspector <br /> Pee:t,y-(-V1? <br /> Physical Address <br /> inspection Date o <br /> 92-Z-0 Time In 0 AM Time Out 0 AM <br /> Business Rep Title .2 pm 1 oZ J 0 PM <br /> IVIA <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) 0 Active 0 Passenger 0 Generator Outdoor <br /> GPS <br /> Latitude 0 @ Closed 0 Altered 0 Hauler 0 indoor <br /> G 0 0 Inactive 0 Truck 0 End Use 0 Container <br /> Operational Business Role <br /> ill one only apply) <br /> (Fill <br /> I all <br /> that app <br /> Active r Generator <br /> I* Closed n <br /> Latitude <br /> Longitude 0 Planned 0 OTR <br /> ed Fuel <br /> Business Type(Fill all that apply) 0 Government 0 Retreader 0 Dismantler 0 Tire Derived <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <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 <br /> 0 <br /> 0 <br /> A HAULING <br /> P <br /> A <br /> R <br /> PRCC <br /> P C <br /> L I <br /> 4 <br /> RC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> P <br /> ENFORCEMENT ENT STATUS <br /> Notice <br /> C M Violation 0 Extension <br /> "Of <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle Date m <br /> 0 C5 / m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements M <br /> 1 CC <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle (Required for NOV or EX7) N <br /> 0 0 <br /> 1 CC <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> U) <br /> 0 0 <br /> 1 CC <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Referred CalRecycle Enforcement <br /> 1 CC <br /> no no 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 /> 010 Other: <br /> [Comments <br /> Inspection Form Included: 0 0�z <br /> Comments Included: Inspector's Siqnature Phone Number <br /> 71134iness Rep's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:* 70 incorrect: E X A M P L E 2 3 <br /> i 0 <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Copy:LEA <br />