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0 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of clef181California I 1 - 1196409 <br /> CalRecycle 781(Rev.y(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- Ir � - O Inspection Type(Fill one) <br /> Site Suffix: J S Routine Q Re-inspection Q Referral Q Observation <br /> Local �- (' If Referral,choose referral type(Fill one) <br /> SIdentifier: J(An J DGS�U 7 n CO"k Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name JJ <br /> p Inspected By Inspector <br /> Physic. Ad ressl 0CSC ()TTV <br /> r <br /> Inspection Date 3 d l 3 <br /> Time In Time Out <br /> Business Rep 11 Title 1 ^ S, O AM 3 O AM <br /> Dou l"IA�1 �QS��(1T V ® PM 6 S PM <br /> Operational Status Tire Type Business Role Storage Type <br /> �( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill that apply) <br /> v 0 Active Q Passenger ® Generator Q Out <br /> Tire Count(Whole/PTE) oor <br /> o Q Closed Q Altered IVhq <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) —1i� <br /> Q New Tire Dealer Q 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 ® Other Lnk6iltAl <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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <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 /> 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 <br /> ®In Compliance-No Violations o <br /> Q Q1 Other:§ <br /> Comments t! 1PSI ^ OL-V- O ���5 ,n� 110' iA <br /> � V�0 dus CltnC,eJ'n, <br /> Inspection Form Included: Q - <br /> Comments Included: e9- <br /> Business R 's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 7X* <br /> E X A M P 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink C y:L <br />