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�Urvey <br /> Waste Tire & Inspection Report inspection Report Number <br /> Cal Recycle State of California I 1 _ 1210474 <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- j Inspection Type(Fill one) <br /> Site Suffix: I S l a ar7 © I IR Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> � <br /> Identifier: San Joe( L'o'-� Coun� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> FQ,f U 5 on Cnc.cP s <br /> Se,S <br /> Physical Addre 3 0 <br /> SOS 1 <br /> C o1,V C. n �� �N Avc , <br /> Inspection Date <br /> csto <br /> CA 1SZv3 <br /> Time In Time Out <br /> Business Rep Title ry O AM 0 O AM <br /> Q PM 3 V ® PM <br /> �j WOI ► L'!Yl 1.1�i'� S -�L1(l�t Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (FII one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active Q Passenger ® Generator Q Outdoor <br /> D Q Closed Q Altered N /A <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) (N <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder IS 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 Q Extension <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 <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 EXT) 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 Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ .._ W <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 /> Comments I �'tfs LL k <br /> +110 <br /> 1� <br /> - U A()�� n (nS <br /> 0 r- i <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Busines ep's ignature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: R*Yi E X A] 1L 62081 <br /> 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:L <br />