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Waste Tire Su, rey & Inspection Report Inspection Report Number <br /> CalRecycle State of California I 1 - 1177825 <br /> CalRecycle 181(Rev.y(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- + C A _ Inspection Type(Fill one) <br /> 5 q ,4 O <br /> Site Suffix: l J A ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San O a�L4 C()lfl(�� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r� Inspected By Inspector <br /> ( it <br /> Physical Address <br /> 7134 W I S�i(e.._ <br /> Inspection Date0 03 <br /> Time In Time Out <br /> Business Rep Title3 Q O AM 3 O O 0 PM <br /> PM <br /> f) S �G U u 2" 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 /> •Active Q Passenger I® Generator Q Ountld000r <br /> O O Closed Q Altered ,V A <br /> GPS Latitude Q Hauler O Indoor <br /> O Q Inactive O Truck <br /> Longitude — Q Planned ! OTR O End-Use Q Container <br /> Business Type(Fill all that apply) 66AAA <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 O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other File <.')f0jr_ <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 /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 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 E)C7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> W <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance-No Violations o <br /> O O Other:§ _ <br /> Comments nn 0 ` S z <br /> -\AAS nJCA <br /> )I 14� Of CA e�S f1 �u�CQ 10- <br /> Inspection Form Included: O <br /> Comments Included: <br /> Business Reps Signature Phone Number Insp c is Signature Phone umber <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 7 V EXAMPLE 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />