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Waste Tire Su, Bey & Inspection Report, Inspection Report Number ■ <br /> CalRecycle state of california I 1 - 1226695 <br /> Recycle) <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> _ _ BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 1 , t _ Q Inspection Type(Fill one) <br /> Site Suffix: "l 1 I* Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: San J V,tii n C01A(l�ti Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> CC�`J, alas. �1h 3 - l 0 <br /> Physical Address <br /> 50`7 <br /> Inspection Date <br /> �\ C'V L' I`` `J Time In Time Out <br /> Business Rep Title G, O AM O AM <br /> rr 1 � � J ® PM � 3 v � PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �(I IS Active 19 Passenger ® Generator 0 Outdoor <br /> GPS <br /> Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR Q End-Use ® Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <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 <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> 2 <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ -- <br /> Comments I N 1 Z- z -�J 2-1 V6-1 t'f) [ADA U11 � AfJ , (A-54 <br /> ak'G�'orb 0} ( l u fl cn! <br /> Inspection FormIncluded: ® •�'35'�K0 <br /> Comments Included: <br /> Business Rep's Sign ture Phone Number Inspe is Signature one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK FCorrect: Incorrect: E X A M P E 11213 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Cop :L © ■ <br />