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Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of california _ — <br /> CalRecycle181(Rev.10/10)lRecycle) Survey Form Page 1 I1 1210486 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 r± ] _ O I Inspection Type(Fill one) <br /> Site Suffix: �( �g ® Routine Q Re-inspection Q Referral Q Observation <br /> Local1 If Referral,choose referral type(Fill one) <br /> Identifier: �n --TdtA 14; n CO tJI�� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �) d- C ��kv { t,lzr 3 - l U l CSC `C3"O <br /> Physical Address � <br /> 0, <br /> Cfl �►53'1`� Inspection Date <br /> Time In Time Out <br /> Business Rep P Title 0 AM i V ® AM <br /> `7fQ ` `t � �c11C�ctI 1 1 �- v U 0 PM I 0 PM <br /> NJ Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) j (Fill one only) (FII all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' J ® Active Of Passenger 0 Generator e Outdoor <br /> o Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ® 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 Q Trucking Fleet Q Government Q Retreader ® 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. 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 /> 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 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 /> 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 Q1 Other:§ <br /> Comments <br /> (1u4h rw W X5 1! i it I)nL (I �i S (I(A)6- d,nc <br /> �-A o w A m w CQ <br /> � .. C <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �j E X A L 1 2 3 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Co : <br />