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........... <br /> Oa Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California - Page <br /> - 1176506 <br /> CalRecycle CalRecyce181(Rev.10/10) 11 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) BLUE <br /> Form Page 1 BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- inspection Type(Fill one) <br /> Site Suffix: I 5 O Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalCo, If Referral,choose referral type(Fill one) <br /> Identifier: San a 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Co 4, W 103 <br /> Physical Address 31 &n e5 o4 <br /> 'A 0 Lan' 0_� s -'sk Inspection Date 0 <br /> �olI a C� Time In 0 AM Time Out 0 AM <br /> Business Rep Title 46 PM 0 0 PM <br /> C)0o %A- Operational Status Tire Type Business Role Storage Type <br /> _j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 50 9 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered 0 Hauler 0 Indoor <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) <br /> N,,Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 40 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 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EX7 <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle EnforcementLu <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 in Compliance-No Violations <br /> 10 0 Other:§ - 7 <br /> Comments k,cuyA <br /> N'O ))I <br /> CM <br /> Inspection Form Included: 0 <br /> um <br /> Comments Included: 0- usin ep lignature Phone Number Inspect s Signature Phon N3her <br /> - 62081 <br /> XA ,ZN <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E X A <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br />