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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br />CalRecycle State of California I 1- 1244949 <br />CalRecycle 181 (Rev. y (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />parr e - Ciirvaw BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />Inspection Details <br />TPID - t '�j 1 <br />1 u <br />O l _ c <br />V <br />Inspection Type (Fill one) <br />Site Suffix: <br />0 <br />40 Routine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 Other <br />Local / <br />Identifier:San J �( <br />0 <br />vL� -IN1/l�fi� <br />0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit <br />Business or Facility Name <br />Sln`te�0EXAV sn� . <br />(�1ec c,c� ESui�r�r,� (.�r,+- <br />Inspected By Inspector <br />`I <br />Physical Address <br />1 <br />_ D 1 <br />0 <br />0 <br />1E S C07T 0 <br />`1030 C- E . Oil bn ��_ <br />J <br />14 CCR § 18459.3 = Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />/ <br />Inspection Date <br />0 <br />0 <br />Time In Time Out <br />Business Rep <br />Title <br />0 AM 0 AM <br />PM <br />�v n -UJ d fit„ <br />1 <br />.epi 4aozkc.4 <br />0 PM p <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 />* Active <br />0 Closed <br />0 Passenger <br />0 Altered <br />• Generator <br />0 Hauler <br />0 Outdoor <br />Indoor <br />O <br />GPS Latitude <br />0 Inactive <br />0 Truck <br />Longitude - <br />0 <br />0 Planned <br />(a OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body <br />0 Car Dealer 0 Collection <br />0 Crumb Rubber <br />0 Service Station 0 Hauler <br />0 Agriculture 0 Shredder ® Other M7ti1�`f�fkl <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CalRecycle <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 = Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments <br />Inspection Form Included: <br />f'_'An <br />\V� oYr��jiLu,S (D1 w"e O� CAAC.etfl_ <br />Comments Included: V- - f <br />Business p's Si nature Phone Number <br />INSTRUCTIONS ON BACK Correct: I. Incorrect: X � V <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EX7) <br />0 Referred / CalRecycle Enforcement <br />0 In Compliance - No Violations <br />Signature <br />AN", <br />Phone Number <br />62081 <br />© ■ <br />