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03 Waste Tire Survey & Inspection Report Inspection Report Number <br /> calRecycle State of California Survey Form - Page 1 11 - 1226579 <br /> CalRecycle 181(Rev.10/10)(CalRecycle) K PEN <br /> Dept.of Resources Recycling and Recovery(Cal - BLUE OR BLACK IN <br /> Part A-Survey inspection Details - <br /> - <br /> Business Profile I n ren e0t <br /> sp ctio 0 a <br /> Inspection Type(Fill one) <br /> TPID- n <br /> 12 0 t Routine 0 Re-inspection 0 Referral 0 Observation <br /> Site Suffix: 10 <br /> Iff ral, referral type(Fill one) <br /> If Referral,choose <br /> Local "'' 0 CHIP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Identifier. S_ _ N(\' C <br /> Business or Facility Name Inspected By Inspector <br /> "115" (1 - I o I /4-rzxm <br /> Physical Address <br /> Inspection Date t ej- <br /> Time In 0 AM Time Out 0 AM <br /> Title <br /> Business Rep 0 'P PM 3 0 PM <br /> Tire Type Business Storage Type <br /> 11 1 that apply) (F,101 Storage <br /> thatyapply) <br /> Operational Status <br /> 1110 ti 0 �a t 11 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active <br /> Generator outdoor <br /> R ® Passenger ® Generator Outdoor <br /> Tire Count(Whole/PTE) 9 9 0 Active <br /> 0 0 Clos 0 It 1 0 1 'or <br /> 0 Closed 0 Altered r 0 indoor <br /> Q Hauler <br /> GPS Latitude 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 Retreadc 1 0 Dismantler 0 Tire Derived Fuel <br /> CNe,Tire Dealer ® Auto 0 Auto Repair U 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 MAN[ TS 0 Notice 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 g Requirements Date N <br /> 0 <br /> A <br /> 0 <br /> H <br /> PRC A <br /> R <br /> PRC <br /> C <br /> C <br /> L <br /> 4 <br /> 4 <br /> N <br /> 2 <br /> 2 <br /> G <br /> 95 <br /> 95 <br /> A <br /> 1 <br /> 3 <br /> AND <br /> Waste a <br /> M <br /> s <br /> Contracts <br /> A <br /> e <br /> ra <br /> MANIFEST <br /> Tire <br /> - - <br /> ENFORCEMENT <br /> STATUS <br /> 0 <br /> of Tires 0 Notice Of Violation 0 Extension <br /> Haulers. <br /> C.'PI..nce Deadline <br /> Q <br /> P 9 Registration/Decal <br /> r tr ni estin Requirements R §42 56-Re t s at f Ig ui <br /> Responsible <br /> 7 <br /> Tire cle <br /> S, 3S within go days <br /> Ret <br /> 0 TC _M <br /> 0 14 CCR§18459-Responsible Entities complying with Manifesting <br /> / m / <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> C� <br /> 8 0 (Required for NOV or EX7) <br /> 0 0 0 1 C §1 9 ve Trip Logs within 90 days <br /> 0 14 CCR§18459.2.1 -Submittal of Comprehensive <br /> 0 0 C § 8 9 Trip Logs for 3 years <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 0 Referred CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> W <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 /> FCoEmments <br /> 1010 ,Other: <br /> Comments <br /> Inspection Form Included: 0 to-(w2&f472 3 <br /> Phone Number <br /> Comments Included: B ness Rep's Signature Phone Number s e or Si a re <br /> re0 Incorrect: XA �� EXAM E 1 2 3■ 62081 <br /> INSTRUCTIONS ON BACK Forct,_ zs� Pink C ® ■ <br /> White Copy:CalRecycle Yellow COPY:operator <br />