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Waste Tire 5Oey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of <br /> CalRecycle1181(Rev.10/10) _ 11 - 1- 3-76721- <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Su rvey Form Page 1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details - <br /> TPID- i, n (_ 1`] Inspection Type(Fill one) <br /> Site Suffix: "t -� lU / 3 - ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local —� <br /> If Referral,choose referral type(Fill one) <br /> Identifier: San J06�,JLItJ� ( uJhf) 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> L.."M D 600-�a Z] <br /> fj <br /> Physical Address 1 L Iv <br /> 1A0 e . wjf�wj, <br /> Inspection Date 1 � / D <br /> Time In ( Time Out / <br /> Business Rep Title . 'S O AM O AM <br /> a O PM ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) �1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Passenger ON Generator 0 Outdoor <br /> GPS <br /> Latitude 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> O 0 Inactive ® 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 0 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 I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§ - 0 Notice Of Violation � Extension <br /> 42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 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 EX7) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> w <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <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:§ L <br /> Comments 6LOZA <br /> v <br /> t ZA� 6� <br /> Inspection Form Included: 0 / � t3QA( <br /> �d <br /> Comments Included: (6 9-3) `9 <br /> Business Rep's ignature one Number Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:Ili Incorrect: �� E X A L F 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y: ® ■ <br />