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Waste Tire 'vey & Inspection Repo rAnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242537 <br /> ry <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> 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- ® _ O Inspection Type(Fill one) <br /> Site Suffix: 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: San J 0 iLln� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0 1 G c,o-rTh <br /> Physical Address p S <br /> 14 l a 1-6 10p, <br /> Inspection Date l / 1 / Li <br /> 0)cn ►533'7 Time In Time Out <br /> Business Rep Tit.lTe `` AM 1 ' ®AM <br /> l iul�Z�pf,1�v� ' O O PM l S 0 PM <br /> L�o s,ur4� a e, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active Q Passenger ® Generator Q Out <br /> or <br /> 7SLatitude 0O Closed O Altered 1\JdA <br /> G <br /> Q Hauler Q Indoor <br /> o Q Inactive ' Truck <br /> Longitude - O Planned 0 OTR O End-Use Q Container <br /> Business Type(Fill all that apply) fur -If+ <br /> Q New Tire Dealer Q Auto Repair ®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 l l <br /> Q Service Station Q Hauler Q Agriculture Q Shredder • 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)CT) N <br /> r <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations <br /> Q Other:§ <br /> Comments � f 1 k,� A)�ja �n k �� <br /> e� 1 f1S(a2c7f'�U'1 b n 1 S � C SL'Inspection Form Include . 0 ZOq�lY-71y <br /> Comments Includ d07 <br /> : �0 <br /> 4Busines'sReps i Phone Number Insactor's Signa re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: EXAM E 1 2 3 162081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Cop L <br />