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Waste Tire"Survey & Inspection Repot inspection Report dumber ■ <br /> Cal Rec cle State of California <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1177892 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , O T� Lk inspection Type(Fill one) <br /> Site Suffix: I 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local1 ( ',� If Referral,choose referral type(Fill one) <br /> Identifier: San Z-9n 4l r1' WtA� 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name NJ <br /> Inspected By Inspector <br /> r <br /> Physical Address , rc' 31 ( b I <br /> Inspection Date 0 / 5 l <br /> Time In Time Out <br /> Business Rep Title I J r O AM O AM <br /> 1 v ® PM 0 PM <br /> �o�amma�r���•b4b o u�ner <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) So (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Caps Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> O 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities —_ _ W <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 1 0 1 Other:§ <br /> Comments '0 ^ 1 Ulfvk <br /> No -- <br /> Inspection Form Included: Q <br /> Comments Included: All /Wk A4�41r9G L�( �/ y6q-7'p�- <br /> ��//��Z VItY1Nti� ��d��� <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Fcorrect:0 Incorrect: X E X A M P E I 111213 620811 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy: ® ■ <br />