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---------- <br /> §-Z-- g <br /> .... ....... <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) 11 - 1196263 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> 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: I � -7 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier cuvo'� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> PhysicVaAdd)re'ss <br /> 33 K_ <br /> Inspection Date <br /> CA CIS 336) Time In d Time Out <br /> Business Rep Title 0 AM 0 AM <br /> I : d__ _-Iy- IV PM 57 opm <br /> \Ij 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 /> 40 Active ® Passenger 49 Generator ®Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use (9 Container <br /> Business Type(Fill all that apply) 0 Dismantler 0 Tire Derived Fuel <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <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 4D Other rl ob 1-t� —/ NL.- )e-/t- C. <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 m m N <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 Enforcement <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 Other:§ <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: *—Z,644 • <br /> Al'y'• Z3 <br /> Business Rep's Signature Phone Number ;I n s Apc t is Sj" t u Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct:40 Incorrect: E X A M L41 1112 3 <br /> M - White Copy:CalRecycle Yellow Copy:Operator Pink Cop <br /> ALV M <br />