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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1245289 <br /> CalRecycle <br /> ndRecev.10/10) <br /> Recovery <br /> 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- � T7 ca <br /> � O � Inspection Type(Fill one) <br /> Site Suffix: o * Routine Q Re-inspection Q Referral Q Observation <br /> Local i � If Referral,choose referral type(Fill one) <br /> Identifier: Sao Jo MI �i`�- � Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C��6' _ I ] <br /> Physical Address , ES l 10-r-To <br /> �vJC" <br /> US��I Inspection Date g / O / S <br /> � � 1 U/ Time In Time Out <br /> Business Rep Title 0 " 0'"AMOAM <br /> �1 Ml't1 LUV,S�eS Pl(,tl1fi m f. I S S 0 PM � � � ® 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 /> 36 ® Active 0 Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> �� La_ if�de Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New TiFe 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 j I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other i p q 1A m kn'UL L.A,!f,r <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 /> Q Q 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 I <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7 <br /> 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 /> 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 (a In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments IRDAM_ LAIkS(� plc, 175 1° Ui1 1 G��INe !/� LVD 1G <br /> (omnoynist 'Form <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> siness Rep's Signature Phone Number Insp tor's Signature Phone Number <br /> -]IIII <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X EXAMPLE 1 2 3 62081 <br /> 0 White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />