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Waste Tire Survey & Inspection Repon Inspection Report Number ■ <br /> State of California <br /> CalRecycle _ <br /> CalRecycle161(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 I1 1177866 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � ,,,, � Inspection Type(Fill one) <br /> Site Suffix: $ U 1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �l ) If Referral,choose referral type(Fill one) <br /> Identifier: San V d aj��1-\ (igLkt-)J'� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name S Inspected By Inspector <br /> Lis C& 4 S�vc,�-cr�-or� 3 � - o <br /> Physical Address , <br /> Inspection Date 0 <br /> Time In Time Out <br /> AM O AM <br /> Business Rep Q�� TitNle� /� 3 A PM PM <br /> 1` 1 tx ►L -"y� IK—a� `' ' nom - 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 /> 131 O Active * Passenger 0 Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 40 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ® 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 Q - Q Notice Of Violation Q Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Datem / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 3 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE 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 /> Ld <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities w <br /> Q Q 14 CCR§18462-Manifest System Requirembnts for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> 1 � n z <br /> Comments f1s 1`o17N L 1 f � N <br /> 0k�_a - <br /> N0 _ji <br /> Inspection Form Included: 0 (/�L, W <br /> Comments Included: ® _-- G T E� b 1 <br /> Busine s Reps Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: )( J� V E X A M L 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />