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1',s �:.1].1S'sta4sB+1M1C,YlS:.:.l A iaisani3s4`Aw.+sysv -aLswtunws•�- •�•,•_-- '...s ..✓ •.u..,.aa-va-u---.is,.>.s.t5.�. ._.,.w...�.t....,...�m......y...d -........�.�+-..uac...ac <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California 11 - 1230336 <br /> CalRecycle 161(Rev. (Ca[ Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Su_"e BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ( c c� 1 O Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ,_ <br /> I If Referral,choose referral type(Fill one) <br /> Identifier: San U— U 1^ Ct��,(1�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> ( ? Inspected By Inspector <br /> Physical Address <br /> 3930 �v. w; 13a� 1��� <br /> Inspection Date 3 <br /> 5�-OC40^ C �SZUS <br /> Time In Time Out <br /> Business Rep Title t D �1 0 # AM I a 0 AM <br /> n �J QPM � � PM <br /> �eJ�DI r� `�1t��nv-� C�wnc/- <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 Passenger Q Generator Q Outdoor <br /> ° ® Closed Q Altered A NIA N J0j <br /> GPS Latitude Q Hauler Q Indoor <br /> ° Q Inactive Q Truck <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 Q Other N,1A <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 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 EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 <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 ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` , � ' � _+� �>�� �,•A � .TrJ 1 l V.�,7��� <br /> n 41 - ��o �►;�1 u'�I u'ls (j C-0 -fit ( - C L Ler n- <br /> es- ( FK C"I 7PIED-. too l wl _01. <br /> �- Cl1D 11, t)n; <br /> Inspection FormIncluded: Q ( 6&A4UW <br /> C>�► -3)�6 <br /> Comments Included: Q qlAw <br /> Bu ess Rep's Signature Phone umber InspVor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect�X ���q E X A M P L E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />