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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRec cle State of California — <br /> Y calRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230333 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- n ` , 1 c V7 _ Q Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: San�ola�� VuU� 0 CHP 0 CalRecycle0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> (9f'z_zn fnt",-) 3 q - [ 0 �s <br /> Physical Address p Rd <br /> COTM <br /> Inspection Date <br /> CA SZ,c7) <br /> Time In Time Out <br /> Business Rep 1 , Title O AMO AM <br /> 0 W rler- S ® PM —1 S is PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) O <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a. Q <br /> 4 Active Q Passenger 9 Generator 0 Outdoor <br /> O 0 Closed IS Altered <br /> �PS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New 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 40 Collection 0 Crumb Rubber < <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other J+d J jc of T!P <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 § 0 Notice Of Violation Q Extension <br /> 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 /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> n <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> LU <br /> W <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 o <br /> 0 0 Other:§ L �y Mcz <br /> L T'Commentso .'[i'fe., 10507 � ( A G0— t413n 6& 1 ' <br /> Y-Q ; o "JI a-Is b I C._JD_cnS tiY Con 0tn . <br /> Inspection Form Included: Q X <br /> Zau � ��39Comments Included. � ^---+ -1 'i T <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Num er <br /> INSTRUCTIONS ON BACK Correct: Incorrect: VX W E X A M L 1 Z 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co y: <br />