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Waste Tire vivy & Inspection Repo, L I,„3pection Report Number <br /> CalRecycle �a;Re�yc e1181(Rev.10/10) -1176497 <br /> ■ <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( � � � n � � _ � I Inspection Type(Fill one) <br /> Site Suffix: ` "� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: San J0 lu,ln cook" 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name l Inspected By Inspector <br /> & <br /> Physical Address <br /> ta01 `F1e'e_k 00&L �av� <br /> S-t ac l�v (, <br /> gSala Inspection Date <br /> `� F <br /> Time In Time <br /> Out <br /> Business Rep Title ((++�� O AM O AM <br /> AU>cr � � � � V � PM � � I --�---19PM- <br /> Q u `v <br /> - <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 /> � <br /> 0 Active 0 Passe`n^ger 0 Generator 0 Outdoor <br /> O 1& Closed 0 Altered--lag hl'A ! A <br /> GPS Latitude 0 Hauler 0 Indoor" ' <br /> � 0 Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station I& Hauler 0 Agriculture 0 Shredder 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments Q _t�T(iL tw�t.�,�fL 1�T�• l.f� P�1�1 n (`^(�f rR2� �fl`T►'l�S (/L-��G q 1\lJ�, ��Q- �, <br /> Ny 4041-ons Ojai-" wnprn <br /> Inspection Form Included: 0 _ p <br /> Comments Included: ® totinGe%N <br /> Business Rep's Signature Phone Number Inspect 's Signatureumber <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E X A P 1 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © . <br />