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A <br /> 0 Vim <br /> 02 Waste Tire Survey & Inspection Report inspection Report Number <br /> State of <br /> CalRecycle CalRecycleCalifornia 181(Rev.10/10)Recycle) Survey Form - Page 1 11 - 1226580 <br /> Dept.of Resources Recycling and Recovery(Cal BLUE OR BLACK INK PEN <br /> Part A Survey---------- <br /> inspection Details <br /> Business Profile <br /> Inspection Type(Fill one) <br /> TPID 00 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Site Suffix: If Referral,choose referral type(Fill one) <br /> Local 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: 's — <br /> Business or Facility Name Inspected By Inspector <br /> CA-TVA - t <br /> Physical AddreS) <br /> Inspection Date <br /> _S,VC_V_1VtTlrA Time In Time Out <br /> 0 AM 0 AM <br /> B siness Rep Titl <br /> 114VL4 I : 6) -3 ® Pm ®PM <br /> Type <br /> Bus <br /> 6f"A Operational Status Tire Type Business Role Storage <br /> I ply) all <br /> apply)(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 0 0 Active 0 Passenger 0 Generator Outdoor <br /> 0 0 Closed 0 Altered 0 Hauler indoor <br /> GpS Latitude 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> 0 OTR <br /> Longitude 0 Planned <br /> Business Type(Fill all that apply) ader 0 Dismantler 0 Tire Derived Fuel <br /> 4D Auto Repair 0 Trucking Government 0 Retre: <br /> New Tire Dealer -et 0 Govenii <br /> 0 Used Tire Dealer 0 Auto Body * 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 /> V A HAULING PRC <br /> P <br /> A <br /> R <br /> PRC <br /> C <br /> C <br /> LIN <br /> 42 <br /> 42 <br /> G <br /> 95 <br /> 95 <br /> A <br /> 1 <br /> 3 <br /> AND <br /> W <br /> C' 'S ENFORCEMENT STATUS <br /> 'ti C M Viol TS 0 <br /> Notice Of 'tin <br /> Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m / m / m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 0 1 §1 9. -Tire Program ID Number from CalRecycle <br /> 0 14 CCR§18459.1 go days (Required for NOV or EXT) 04 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Referred/CalRecycle Enforcement <br /> 2 <br /> 0 0 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 Lu <br /> 14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> 0 0 <br /> 0 0 Other:§ <br /> [Comments — <br /> Inspection Form Included: -7 <br /> Phone Number <br /> Comments Includ e hone Number In e or's Si n re <br /> Busines.—.— atu 62081 <br /> Incorrect: E X A M P L 1 2 3 <br /> ■ <br /> INSTRUCTIONS ON BACK Correct: V_\ i� ��l <br /> Pin Co <br /> ■ White Copy:CalRecycle Yellow Copy:operator <br />