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Waste Tire c*Wy & Inspection Repo r spection Report Number <br /> Cdecycle State of California I 1 - 1226557 <br /> Caycling le 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 Type(Fill one) <br /> Site Suffix: z Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -Tck::4 ry% Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> , 11 Inspected By Inspector <br /> Physical Add ess/ C3Yl1GY �-Gt.� CS J <br /> ttCtNtG1��1'1 <� <br /> Lk_?_Z Lj (A.,) A <br /> � Inspection Date <br /> �sils- <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> r u C) ® PM v C) O ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I* Active ® Passenger ® 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 /> Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q RetreaderV 0 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 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. j Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / F11 <br /> / 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 /> 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 �®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments112 <br /> —- 4�-,-u� c�i.�f ice.✓ �j-�-C'�C��G� GtiYtCf1 `��--�-' - - — <br /> L�c' i2a fc-cam-[ <br /> Inspection Form Included: Q . ....... <br /> Comments Included: <br /> B mess Re s Si ur Phone Number spector's Signature Phone NumberE <br /> INSTRUCTIONS O Cor ect: Incorrect: <br /> X A M P L 1 2 3 szosl <br /> --- - - <br /> White Copy:CalRecycle Yellow Copy:Operator Pink opy.L <br />