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Waste Tire Survey & Inspection Report Inspection Report Number <br /> Cal Recycle State of California I 1 - 1230129 <br /> CalRecycle .Recov.10(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- inspection 0 Inspection Type(Fill one) <br /> Site Suffix: O 1 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local �" j If Referral,choose referral type(Fill one) <br /> Identifier: San n JA�q ut/) 6o un Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name O <br /> !� I � � Inspected By Inspector <br /> ad- <br /> Physical Address J J ( 1 E S(OTTO <br /> a Z0a S . )) <br /> ,I,�' Inspection Date <br /> Time In Time Out <br /> Business Rep Title ® AM ) a AM <br /> 0 PM l I O 0 PM <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 /> Q Active Q <br /> Penger Q Gnenfraator Q Out oo <br /> r <br /> 0 f\1e " �>� <br /> PS Latitude Closed QAlter Y49 "'T <br /> OQ Inactive Q Truck Hauler Indoo`r <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 <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 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 /> W <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> U v i+v....n y iuiv�-iviai uicai.�ya�cui rcywi cincnio ivi Tuc � In Compliance-No Violations o <br /> Q Q Other:§ 1- - 1 <br /> Comments �fl`�l r-- r S u <br /> W p,S CAy J"01" '�-�i 6-f Care Ct7'1C Pel <br /> N arcs l.^C e�b5 U�� ns k r�- i�� t <br /> Inspection Form Included: Q to <br /> r-� <br /> Comments Included. 0---- - - - W� 6g 31-/L <br /> Business Rep's Signature Phone Number nsp or's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: g E X A E fl2l3 <br /> 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pi © ■ <br />