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a Waste Tire St,. vey & Inspection Repor ,, Inspection Report Number <br /> Cal Recycle state of California I l - 1242500 <br /> Caycling le i8l(Rev.y(CalRecycle) Survey <br /> S rvey Fo �Fi(�l o Page it <br /> Dept.of Resources Recycling and Recovery(CalRecycle) V{'�� CJ lw tl fel II1l IBJ 11 Q ��ii <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 r q s a _ Inspection Type(Fill one) <br /> Site Suffix: I �Q 1 ' Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San u U u� Co ut Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I / Inspected By Inspector <br /> - Co - �0rce- 850 Lk� Qn C C�" 0 2, 1 _ Q ' b <br /> Physical Address <br /> S3'�� <br /> CA Inspection Date <br /> q <br /> Time In Time Out <br /> Business Rep Title l 9 AM I O AM <br /> O PM Y O ® PM <br /> - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) i (Fill,one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 1 ® Active 9 Passenger ® Generator Outdoor <br /> GPS Latitude 0 Closed Q Altered <br /> Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> _) New Tire Dealer 0 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 /> Q 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> QQ 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date Ifl / M / Ffl <br /> Q 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 EXE n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Uj <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 /> A�o was <br /> �1�ay i���-i o� �f [l�,i��►s .�' Gun den n <br /> Inspection Form Included: Q6 "'26L H6 t-30 <br /> Comments Included: <br /> Business Rep' Signature Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAM L 112 13 1 <br /> 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop -.L <br />