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Waste Tire Survey & Inspection Report `inspection Report Number <br />cal Recycle State of California I -1176700 <br />CalRecycle 181(Rev.(CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />part A - lRiirvav BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />TPID - O <br />Site Suffix: I `� f <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Inspection Type (Fill one) <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 Routine 0 Re -inspection 0 Referral <br />If Referral, choose referral type (Fill one) <br />0 Observation <br />Local <br />Identifier: Sao Ja t ^ &j,�(�� <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 CHP 0 CalRecycle 0 Complaint <br />0 Educational Visit 0 Other <br />Business or Facility Name <br />L_P,Jmu,P �co �� us S <br />nc. <br />Inspected By Inspector <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />c .�o1. <br />Physical Address <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />- <br />3 I Q I <br />ESCOff,() <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />II <br />���� E FfemvnG ST. <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />S_ to LrZI ^ <br />� 15 <br />Inspection Date I d / <br />0 <br />Time In <br />Time Out <br />Business Rep Title <br />C/�) 0 AM <br />I <br />O AM <br />1 v <br />V 0 P <br />0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />/�j{ <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />w <br />0 Active <br />ger <br />0 Passenger <br />0 Generator <br />0 Outdoor <br />® Closed <br />0 Altfi/A <br />n <br />, A <br />NIA <br />O <br />GPS Latitude <br />0 Hauler <br />0 Indoor <br />0 Inactive <br />Q Truck <br />Longitude — <br />0 <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />_ <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet <br />0 Government 0 Retreader 0 Dismantler 0 <br />Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer <br />0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture <br />0 Shredder 0 Other NO <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />l 1 <br />Comments <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />® In Compliance - No Violations <br />blAl <br />fls n S o, C.o kern . <br />N <br />Inspection Form Included: 0 <br />Comments Included: 0 <br />Business Rep's Signature Phone Number Insp tor's Signature Phone Number <br />/ � <br />INSTRUCTIONS ON BACK =Correct:* Incorrect: X NJ E X A M 3 62081 L 1 2 <br />■ White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LE © 0 <br />y <br />�o <br />N <br />a <br />N <br />0 <br />Lu <br />Lu <br />