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r Inspection Report Number <br /> - -Wast- TimSurvey-&Inspection-Report <br /> CalRecycle State of California I 1 u 1210408 <br /> CalRecycle 181(Rev.y(Cal Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> P- +A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> + � � � _ © ( Inspection Type(Fill one) <br /> Site Suffix: t of ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / ( If Referral,choose referral type(Fill one) <br /> Identifier: San 3 0u' 1 aItfl lam'") :n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address v ' V <br /> 000 W <br /> "lSZ�3 Inspection Date Q <br /> Time In Time Out <br /> Business Rep Title ® AM AM <br /> 1 1 S O PM 3 O PM <br /> CSfiC�,�2,'Cn 0r ULA U�i t.2 {Yl c. -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r x (Fill one only) (Fill all that apply) (Fill all that apply) (FII all that apply) <br /> �(J Q Active Q Passenger Q Generator Q Outdoor <br /> l <br /> o ® Closed Q Altellp N N 1 x� <br /> GPS Latitude Q Hauler j Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type(Fill all that apply) <br /> Jew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Jsed 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 1� <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 <br /> 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 O 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV cr EXT n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments L _.I 1, �' An <br /> (c A U I�1 GN 61 1 ,G( ,J�u_� X0S9-&(k-_0n �� N <br /> Q� C�� n l� S 0D �lj N U -V 1 lti rt�n S 03 (- - Lb p(1)- <br /> _Kc� c f !1!L/ t, �'1 t,S n Gy1 <br /> . of lip <br /> .-pection Form Included: Q <br /> Comments Included: Q X07 y -%t?- <br /> Business Rep's Sig ure Phone Number Insp tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: 7X V E I X I A I M I P E.1 1112131 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />