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Waste Tire S&ey & Inspection Repor Inspection Report Number <br /> Cdecycle State of California I 1 - 1226284 <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- Inspection_ r Inspection Type(Fill one) <br /> Site Suffix: 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam <br /> Inspected By Inspector <br /> Physical Address C� 1 r30IC 12T_ �N <br /> Inspection Date <br /> CA <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> © Z I S ® PM O 3 a Q PM <br /> GYlO &o z- s 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 ® Generator Q Outdoor <br /> O 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) Nj A NIA <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 Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other C� ;� ) CL!wt 4 WC- ROCi <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 Dateb l MAI <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 EX7) N <br /> a <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 10 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 Q In Compliance No Violations o <br /> Q 1 Q 1 Other:§ <br /> Comments < <br /> .L1Yt�'�4 It ►YSTCfL�L`CJv`• "�n.�C �aLP.t��. GM�� '4"�� <br /> Ll crn1 ►iv W(,fit VSO tcn" = <br /> Inspection Form Included: Q <br /> Comments Included: <br /> LZc>� ) il6 2 3 <br /> Busine s Rep's 'gnature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONSK ON BACect: Incorrect: EXAM 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />