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Waste Tire Survey & Inspection Report Inspection Report Number . Cal Rec cle State of California — Y CalRecycle (Rev. (Cal Survey Form - Page 1 I1 12 2 6 2 3 4 Dept.of Resources Recycling anddRecovery(CalRecycle) Part A- Survey BLUE OR BLACK INK PEN Business Profile .Inspection Details TPID- Q Inspection Type(Fill one) Site Suffix: 1 "� * Routine Q Re-inspection Q Referral Q Observation Local ( If Referral,choose referral type(Fill one) Identifier: San J Ou�tl.�to `�un�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other Businessor Facility Name ` Inspected By Inspector CD- Physical Address 1 v es(Ao lbs E . Wrti �rlvU �c�l . e1 11 L�,, 1 C Inspection Date f a s I� Time In Time Out Business Repf�/� ` 1 Title I 0 AM I, O AM ® PM— � ® PM Operational Status Tire Type Business Role Storage Type Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) 0 Active Q Passenger 18 Generator 0 Outdoor Q Closed Q Altered GPS Latitude Q Hauler ® Indoor D Q Inactive * Truck Longitude - Q Planned ® OTR Q End-Use Q Container Business Type(Fill all that apply) Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber f_ Q Service Station Q Hauler Q Agriculture Q Shredder ® Other �ra"t (f)Aflq�(.te_tv ,,F 1reP9Ai'r Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS V A HAULING AND MANIFEST REQUIREMENTS Q Q PR - - Q Notice Of Violation Q Extension C§42951 Waste Tire Hauler Registration and Transport of Tires Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline PRC§42956-Registration/Decal in Vehicle Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE n Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years 0 Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o Q Q Other:§ ` 1 ]� Comments �_uJA1�\ 2,nl.��UIST ,�lJe.I,fl I Jac. Un �nl S � Cz MYX 1 YOU r)11(11A) )11All� O�lk�i unS _(k s ut U. nco0 Inspection Form Included. Q Comments Included: ®- - - - - -�r'Business Rep's Signature Phone Number IrePhone Number INSTRUCTIONS ON BACK Correct: Incorrect: ! E X A E 1 2 3 62081 ■ White Copy:CalRecycle Yellow Copy:Operator Pink C y EA © .