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-Z -- ---- <br /> 03' Waste Tire burvey & Inspection Repo, i Inspection Report Number ■ <br /> Cdecycle State of California 1176461 <br /> CalRecycle <br /> 181(Rev.10/10) 11 - <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey 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: l 3 15Q 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 46_,, 4m.6 ;' <br /> i I'� <br /> v ' <br /> Physical ddress <br /> 6,33 so_rt 30art kvc- Inspection Date <br /> , / a3 <br /> CA <br /> Time In Time Out <br /> Business Rep Title 0 AM AM <br /> 0 0 PM f 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> S ® Active 0 Passenger IS Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 indoor <br /> 0 0 inactive Truck <br /> Longitude 0 Planned OTR 0 End-use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 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 /> 0 service station 0 Hauler 0 Agriculture 0 Shredder Q 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 <br /> m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) N <br /> U) <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 Enforcement <br /> 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 In Compliance-No Violations <br /> 0 0 Other:§ <br /> Comments <br /> Inspection Form Included: b7 z4a t6-7 <br /> Comments Included: ssR p i abur Phone Number Ins c or's g ature Phone Number <br /> * incorrect: vz (Z�, �� / 62081 <br /> Correct: <br /> INSTRUCTIONS ON BA K A W I E X A E/ <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink fl 0 <br />