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y Inspection? <br /> Tire , �e & Ins Re �. Inspection Report Number <br /> Waste p p ° � <br /> CalRecycle State of cleCalifornia81 ) T — 1176376 1 7 6 3 7 6 <br /> CalRecycle 181 Rev.10/10 Survey Form - Page 1 1 1 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ BLUE OR BLACK INK PEN <br /> Part A-Sme <br /> Business Profile Inspection Details <br /> TPID- Inspection G a - O I Inspection Type(Fill one) <br /> Site Suffix: l I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local \ l If Referral,choose referral type(Fill one) <br /> Identifier: San J(o c `u ll n lnuf)� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> U,nkv_�) - ; cam 3 - � <br /> Physical Address I ��� � <br /> Wn <br /> Inspection Date `7 <br /> An OJ L�b n 5�4� <br /> Time In Time Out <br /> Business Rep Title (� O AM O AM <br /> \! 3 v 0 PM S ® PM <br /> Operational Status Tin:Type Business Role Storage Type <br /> Tire Count (Whole/PTE) I e-I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I ® Active • Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q 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 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 m / Ffl <br /> / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a <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 Q Referred/CalRecycle Enforcement <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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:§ Y <br /> Comments I S <br /> QtA 1-i <br /> IN b v ioja� one, [cA5 C71' Cb f)cr�-n <br /> 8 Inspection Form Included: O A ' 1 <br /> Comments Included: ® NL�\ L /� ��eg'1� <br /> Business R s Signature P one umber lnspe is Sigrv. �� <br /> p Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A P L14 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />