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......... . <br /> ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1226581 <br /> CalRecycle 181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(calRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Proffile____----.--- Inspection Details <br /> Inspection Type(Fill one) <br /> TPID- Observation <br /> Zite rSuff ix: 114 14 1 0 1 Ct - 01 0 Routine 0 Re-inspection 0 Referral 0 Obselrvation <br /> If Referral,choose referral type(Fill one) <br /> Local <br /> Identifier: 1-^hj 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -T;-< L")in lot <br /> Physical Address <br /> 144 1 Lj E, q5010 5 Inspection Date <br /> b c��U� &A I Time In 0 AM Time Out 0 AM <br /> Business Rep Title —7 0 PM C S7 WPM <br /> C_Vf1VMy_(__) A?v rl&f, R <br /> Operational Status Tire Type Business Role Storage Type <br /> Operational <br /> one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active <br /> 0 s er to Outdoor <br /> Tire Count(Whole/PTE) or ® Outdoor <br /> 1 9 5' 0 Active Passenger Generator <br /> —0 0 Closed Status <br /> OAltered "_".r 08 door <br /> 0 Hauler in <br /> GPS Latitude 0 0 Inactive 0 Truck 0 Indoor <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 10 Auto Repair 0 Trucking Fleet 0 <br /> Government <br /> (1) 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 <br /> 0 <br /> HAULING <br /> 0 P <br /> A <br /> R <br /> PRC <br /> C <br /> C <br /> L N <br /> 42 <br /> 42 <br /> G <br /> 95 <br /> 95 <br /> A <br /> 1 <br /> 3 <br /> AND <br /> WasteW <br /> Co <br /> s <br /> n <br /> t <br /> t <br /> A <br /> e <br /> ra <br /> MANIFEST <br /> c <br /> i r <br /> t <br /> F <br /> Tire E <br /> w <br /> Hauler S <br /> a <br /> with T <br /> u'e <br /> R <br /> R <br /> r <br /> Registered E <br /> Registration <br /> Q <br /> e <br /> is <br /> g <br /> U <br /> is <br /> ter <br /> t <br /> e <br /> ra <br /> d <br /> I I REQUIREMENTS <br /> t <br /> Waste <br /> 0 <br /> a <br /> n <br /> t <br /> s <br /> and N <br /> e <br /> n' <br /> I <br /> ENFORCEMENT STATUS <br /> 7S <br /> C M <br /> Notice Of Viol 0 <br /> Compliance <br /> c <br /> an e Dea <br /> 0 PR 42956 Reg st'a i, /Decal Vehicle <br /> m <br /> Extension <br /> 1 0 ply" <br /> 5 Number <br /> from <br /> rr <br /> Comprehensive <br /> " <br /> Comprehensive <br /> Requirements <br /> m r <br /> C§ <br /> m / m / m <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> S <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 2 <br /> Lu <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 /> 0 0 <br /> Other:§ <br /> 1 <br /> Comments <br /> (:f,,n <br /> Inspection Form Included: 0 <br /> lu <br /> Comments Included: or's i ature Phone Number <br /> Business Rep's Si nature Ph ne Number <br /> 62081 <br /> EXAM 1 2 3 <br /> rrect:0 Incorrect: ,N <br /> X <br /> INSTRUCTIONS ON BACK r�_O_ Pink Copy: <br /> ■ White Copy:CalRecycle Yellow COPY:operator <br />