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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177515 <br /> CalRecycle R(Rev.y(CalRecycle) Survey <br /> 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- ' I i C _ Q I Inspection Type(Fill one) <br /> S <br /> Site Suffix: l l0 J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San U0 c tq (J(1 f� C()ltfl Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l 1 Inspected By Inspector <br /> �R A' r Sk't�C__ CQnVeI' <br /> Physical Address I - V 1 r ® (Es(-OTT0) <br /> �da5 1�9CAv � Qr_ <br /> sic)L��On �� v15Z�� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM 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 i Generator Q Outdoor <br /> O Q Closed Q Altered MIA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned Q 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 <br /> 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 <br /> 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) <br /> rL <br /> 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 /> 2 <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 o <br /> Q Q Other:§ <br /> �Comments <br /> L ux`t ' 1 <br /> J —N LchSi'c_ �C� r I O c.T1tt� (J�Os� 0/1��1�S s� �►�(1 r <br /> Inspection Form <br /> Included-0 u - ee <br /> J//IJ- /0Comments Included:� —���� ��O <br /> Business ep's Si nat Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: >� E X A L 1 : 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co <br />