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Waste Tire Sup vey & Inspection Report Inspection Report Number <br /> ■ calRecycle CalRecyce"181n(Rev.10/10) — <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Survey Form - Page 1 I1 1196371 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r 1 1 _ Inspection Type(Fill one) <br /> Site Suffix: �l L ® Routine Q Re-inspection Q Referral Q Observation <br /> Localr�-\"' If Referral,choose referral type(Fill one) <br /> Identifier: San V�CIG�J11 n �L�C� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 11\ Inspected By Inspector <br /> D; v;S-W ��urn>?0ft ,�0, _ <br /> Physical Address � 1 0 1 CJ co-n <br /> 51 ('�k W . � k-"— Sk- <br /> _Tsc,, ,� g53o'� <br /> Inspection Date � � ' r7 � 1 1 <br /> C1� 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' S ® PM U ® PM <br /> �a, U\, t' bv.�nc r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � 1 <br /> ® Active ® Passenger a Generator S Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Indoor <br /> 0 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 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 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 /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle a <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 o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <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 /> CommentsAl P r s rb 'O-Vf� V6� N <br /> Inspection Form Included: Q 1 <br /> Comments Included: ® ( (P J <br /> Business R p's signature <br /> e Phone Number Insp c or's Signature Phone Number <br /> �,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: NJ EXAM L J-'1112 62081 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cope:L <br /> ■ <br />