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Waste Tire Survey & Inspection Report 4nspection Report Number ■ <br /> CalRecycle State of California 11 - 1226347 <br /> CalRecycle 181(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecyclei <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' \ / Inspection Type(Fill one) <br /> Site Suffix: I `p S ® Routine Q Re-inspection Q Referral Q Observation <br /> Local (J If Referral,choose referral type(Fill one) <br /> Identifier: <br /> San J G(,LL'j 1 lin Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> LkI <br /> k A��� ��S�un ('r 3 9 - , CsGo <br /> Physical Address <br /> ��� Inspection Date 3 / I 5(A T1 <br /> Time In Time Out <br /> Business Rep Title V (Do 0 AM ' I 10 AM <br /> �C_ O PM O QPM <br /> b n Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � 5 � q <br /> 0 Active I&,Passenger ® Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader 0 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 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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date 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 EX7) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years U) <br /> 0 <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 In Compliance-No Violations <br /> Q Q Other:§ <br /> Comments 00 <br /> C G –Ir 1 , <br /> ,AOI`,n -5 n)�e�l 11 <br /> Inspection Form Included: <br /> Comments Included: ® --`' _—303 - — �`�--""�' ) <br /> Business Rep's Signature Phone Number Insp tor's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK [Correct-0 Incorrect: M W V <br /> E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy © ■ <br />