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02 Waste Tire e & Inspection Re o Inspection Report Number <br /> CalRecycle y p p <br /> State of California <br /> Y CalRecycle 181(Rev.10110) Survey Form - Page 1 1 - 1230308 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- 1 Inspection Type(Fill one) <br /> Site Suffix: 3 Q 0 t ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: Sto JOaq 111 n �un� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l Inspected By Inspector <br /> Ott <br /> Physical Address <br /> 33 saw J��r Ave- . <br /> Inspection Date a 0 3 <br /> ( QD? Time In Time Out <br /> Business RRep1) Title /� AM O AM <br /> 3 : Q ® PM �+ 3 v � PM <br /> NJ 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 /> 0 Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered 121 <br /> GPS Latitude Q Hauler Q IndO6r' <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 0 I <br /> Q New Tire Dealer Q Auto Repair ® 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 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 Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 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 /> f <br /> W <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <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 /> Comments 1 N <br /> •/ r�S Oj <br /> Inspection Form Included: QN-0 <br /> / „�� <br /> Comments Included: `�i � � X I <br /> Bu a 's S' ature Phone Number Inspe is Signature Phone Number <br /> �,( 62081 <br /> INSTRUCTIONS ON BA rrect: Incorrect: � 1W �J E X A M L E 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: <br />