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Waste Tire SAey & Inspection Reporp Inspection Report Number <br />CalRecycle State of California I 1 - 1245018 <br />CalRecycle 181 (Rev. (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 Type (Fill one) <br />Site Suffix: 1 1 d 2- O 1 . Routine Q Re -inspection Q Referral Q Observation <br />Local <br />Identifier: <br />Business or Facility Name JLC <br />Physical Address <br />-703o CA, V;-cbv\ 5-�, <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />59 - 1a� MpT,Nv <br />�y�, C'C� <br />'5 ' <br />Inspection Date <br />O 5 / 1 Q / 1 S <br />"��Y\ �+ <br />Time In <br />Time Out <br />Business Rep Title <br />Business <br />& AM i o 1 AM <br />1 <br />QOY" ITC6C� <br />' <br />d Q PM + O 0 PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />40 Active <br />Q Closed <br />* Passenger <br />Q Altered <br />0 Generator <br />Q Hauler <br />, Outdoor <br />Indoor <br />O <br />GPS Latitude <br />Q Inactive <br />, Truck <br />O <br />Longitude - <br />Q Planned <br />OTR <br />Q End -Use <br />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 <br />Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Other <br />Ma Ae-nwr z- �A <br />Part <br />B - <br />Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />ENFORCEMENT STATUS <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m/ m / m <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />A <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />N <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />o <br />Q <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred / CalRecycle Enforcement <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />W <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />• In Compliance - No Violations <br />o <br />Q <br />Q <br />Other: § <br />Comments <br />,:-A-. rAe <br />Inspection Form Included: Q <br />Comments Included: Z�� 4�-110 Z �` <br />Business Rep's Signature Phone Number Inspe tor's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect: V 62081 <br />V A E X A M P L E 1 2 3 <br />White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />