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Waste Tire c*ey & Inspection Repor Inspection Report Number <br /> CalRecycle State of California I 1 - 1176662 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> 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- -7 Inspection Type(Fill one) <br /> Site Suffix: 3 ? i Z 3 T ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� --l- �" „ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name .J <br /> Inspected By Inspector <br /> NJ MIC ��� G <br /> Physical Address3 / <br /> 630 E F277�V <br /> 1 2- 31 <br /> Inspection Date 40 / ® 2 <br /> =+-aC,� 4 SZo3 � <br /> Time In Time Out <br /> Business Rep Title O AM > Q AM <br /> ® a2 ® PM 0 PM <br /> - <br /> - — 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 /> SP Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o ® 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 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> --- --- --- --- - _.__ --- <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 m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> (Required for NOV orEX� <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days N <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 /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q O Other:§ <br /> Comments <br /> G L � i71 �L�f-ice 74741 l&tt G'6�yse r J Q �2C� <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> ,- 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect -� tVJ EXAM L 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy: E <br />