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Waste Tire Su, Bey & Inspection Report <br />CalRecycle State of California <br />Dept. of Resources RecyclingRcle and Retc very (CalRecycle) Survey Form — Page 1 <br />Part A - RlIrvPV <br />-Inspection Report Number ■ <br />I1 -1226597 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - C7 <br />Site Suffix: 6 <br />Inspection Type (Fill one) <br />c� <br />(a Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier: San J �� �1 Y � � 6tii��� <br />// <br />Business or Facility Name <br />Inspected By Inspector <br />Phys��icalAddie s <br />( 0 ( �rn� <br />Inspection Date z I 1 / i f <br />l/ C <br />ciw 4-ec C� Q533� <br />r <br />Time In Time Out <br />Business Rep Title <br />® AM ® AM <br />0 L S OPM �% J O 0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />t. <br />QP Active <br />Q Closed <br />Q Passenger <br />O Altered <br />® Generator <br />0 Hauler <br />® Outdoor <br />0 Indoor <br />O <br />Gies Latitude <br />O Inactive <br />® Truck <br />O <br />Longitude - <br />O Planned <br />O OTR <br />O End -Use <br />0 Container <br />I - <br />Business Type (Fill all that apply) <br />(a New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Service Station Hauler Agriculture Shredder Other 1 <br />9 ® <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />I HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date M/M/m <br />Q <br />O <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EX7) <br />O <br />O <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />__ <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® In Compliance - No Violations <br />O <br />O <br />Other: § <br />Comments <br />Inspection Form Included: Q <br />® 7. ;3 � <br />Comments Included: <br />_►'� <br />Business Rep's Signature Phone Number n or's nature Phone Number <br />INSTRUCTIONS)ON BACK <br />�orrect: Incorrect: <br />E <br />A <br />L— <br />I <br />I 1 <br />273 <br />62081 <br />r� <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />■ <br />