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Waste Tire SL . ✓ey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1226306 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type(Fill one) <br /> Site Suffix: J 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San JOa�u � C�u�1�1� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name N Inspected By Inspector T <br /> Physical ��V`2� ��C* v l I.�S COTTO <br /> c� �SwL Inspection Date S $ l 3 <br /> Time In Time Out U <br /> Business Rep Title 0 AM AM <br /> 1 l , l O O PM 1 5 O PM <br /> c�u�nv- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> o (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active • Passenger 9 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive ® Truck <br /> Longitude — Q Planned 4P OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ® Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 / m <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 <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years N <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 a 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ► —buT') \AG�,Ju JC. 1 1 t cktAkc ovYi1 N <br /> AAs Qr��l <br /> Inspection Form Included: <br /> Comments Include �b t <br /> usiness Rep's Signature Phone Number Insp tor's Sig ure Phone Number <br /> INSTRUCTIONS BACK Correct: Incorrect: W E X A E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop : A <br />