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Waste Tire S ey & Inspection Report'slnspection Report Number <br /> State of <br /> CalRecycle CalRecyclel1181(Rev.10/10) <br /> Survey Fora - Page 1 I1 - 1196365 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- C n _ Inspection Type(Fill one) <br /> Site Suffix: J J `� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> I <br /> Identifier: San O 11. IAlr,1 c"c� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physicddrer 5 e ! C S <br /> 1� 1(7 CoX ?-A- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title g ® AM Q AM <br /> QPM I � v V � PM <br /> 111 uk%V_r►� � Conn-kp S'tvs <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 /> 0 * Active 0 Passenger (6 Generator 0 Outdoor <br /> O I�.V1 n <br /> GPS Latitude 0 Closed 0 Altered A <br /> 0 Hauler 0 Indoor <br /> O 0 Inactive 4P Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use 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 0 Car Dealer 0 Collection 0 Crumb Rubber II ( 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 16 Other bCAS <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance-No Violations o <br /> 1010 1 Other:§ <br /> Comments <br /> bJ (A) UA1 <br /> Inspection Form Included: 0 / <br /> Comments Included: 411141n <br /> -Business Rep's Signature PhoneNumber or's Signature Phone Number <br /> • k�q 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P E 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co :LEA © ■ <br />