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- - ------- - <br /> ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of <br /> CalRecycle CalRecycleCalifornia 181(Rev.10/10) Survey Form - Page 1 11 -1176827 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE OR BLACK INK PEN <br /> PartA-Survey I <br /> Inspection Details — <br /> FB—Us—ine—ssProfile <br /> inspection Type(Fill one) <br /> TPID- __7 C) 1 10 Routine 0 Re inspection 0 Referral 0 Observation <br /> Site Suffix: fill <br /> If Referral,choose referral type(Fill one) <br /> cL "S <br /> Local Co 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> F 0 CHIP <br /> Identifier: <br /> Business or Facility Name inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> CA Time Out Time In 0 AM 0 AM <br /> : <br /> Business Rep Title 0 0 PM PM <br /> V,_- b-v Vy"r- Operational Status Tire Type Business Role Storage Type <br /> (Fill <br /> 1 apply) <br /> ( <br /> ill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active <br /> 'r tor <br /> Tire Count(Whole/PTE) 10 Active 0 Passenger 10 Generator 0 Outdoor <br /> —0 0 Closed 0 Altered n I <br /> 0 Hauler 0 Indoor <br /> FrpS Latitude <br /> G 0 0 Inactive 0 Truck 0 End-Use 0 container <br /> Longitude 0 Planned 0 OTR <br /> Business Type(Fill all that apply) 0 <br /> Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 4D New Tire Dealer 0 Auto Repair Trucking Fleet <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> New Tire Dealer 0 Auto <br /> 0 Used Tire Dealer 0 Auto <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 ENFORCEMENT <br /> Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <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 /> U) <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle T <br /> (Required for NOV or EXT) C� <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Ln <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years �R <br /> 0 Referred/CalRecycle,Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities Lu <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 /> --12W-y"Cna /'n <br /> Inspection Form Included: 0 <br /> ao�L6 01 q\�b <14,F-?Z, <br /> I lu Phone Number <br /> Comments Included: 6usi Phone Number IM e Si a <br /> ,..,Rep's Business R�ep's Sijgnature <br /> 62081 <br /> 1 2 3 <br /> INSTRUCTIONS ON BACK ECowe rrect:470incorrect: E X A ■ <br /> Pi*C <br /> White Copy:CalRecycle Yellow Copy:operator 0 <br />