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Waste Tirevey & Inspection Rep - Inspection Report Number ■ <br /> CalRecycle Cte of aaRecyclelffornia 181(Rev.10/10) 11 -1176841 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form — Page 1 <br /> Part A -_Survey BLUE OR BLACK INK PEN <br /> Business ss Profile p — _ <br /> Ins ection Details <br /> TPID- 1 c� + - O Inspection Type(Fill one) <br /> Site Suffix: ` 2 3 V I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San J6 p�� LkA j) CC)M� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name "`"t Inspected By Inspector <br /> I I <br /> 1�131 C� 1 0 - rte, w 3 l D 9cnPhysical Address (ES 7,0 <br /> Inspection Date 7 <br /> Time In Time Out <br /> Business Rep /� Titlee_ 0 AM r, O AM <br /> I1 1 1 ' SV1// 5 O ® PM I V ® PM <br /> - - ---- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) /�( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' • Active Q Passenger ® Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered N/A <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned ® 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 9 Other V fckJ0r S�4LS <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 Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EXE N <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 /> 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 ®In Compliance-No Violations o <br /> Q Q Other:§ �.! l (NaComments � �i t J' W 1�'�tU[i� (7 _,� 0.n" 1SA tb <br /> Inspection Form Included: j (/ �( <br /> Comments Included. (911, ----- -- -- 70/� (,2� <br /> Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 62081 <br /> � v) EXA L E 1112 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink QA.0rEA © ■ <br />