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0 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Cal Recycle State of California I 1 - 1210439 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept,of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- S n _ O Inspection Type(Fill one) <br /> Site Suffix: I "� 1 Q Routine Q Re-inspection Referral Q Observation <br /> Local �l. If Referral,choose referral type(Fill one) <br /> Identifier: San J O lel IN cb u,n L Q CHP 0 CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ' , r, �-T-F <br /> Inspection Date ` / o / 3 <br /> Time In Time Out <br /> Business Rep Title0 O AM 0 4 AM <br /> e-r � � 0 PM I `' S 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ® Closed Q Alter NN Q Haule/6 Q Indo6rr 1�b <br /> GPS Latitude <br /> o 0 Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> used Ire ea er Auto Body car ueaier Collection Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q 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 <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ®In Compliance- No Violations o <br /> Q Q Other:§ <br /> �1 I z <br /> Comments ] l'1 'S LA?-) -T?'z S U —© ��_ �iLC� 'L -- <br /> Inspectiort-Forrlrirncluded. — <br /> Comments Included: 01 1 <br /> LD9 - <br /> Bu iness Rep'sjCnatyg Phone Number t Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK I C recta ncorrect: EXAMPLE I 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® ■ <br />