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Waste Tire SL..vey & InspecUon Rep®rL Inspection Report Number <br /> cal Recycle State of California p�. I 1 - 1242486 <br /> CalRecycle 181(Rev.y(Cal S p B irve�/J p..o r!'f'Sl s Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) NJ�d I� hi,J Form 1� Page <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 C 1 i a _ M Inspection Type(Fill one) <br /> Site Suffix: J "l 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ^�11 If Referral,choose referral type(Fill one) <br /> Identifier:. < n J��1��n CU An Q.CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 31 0 <br /> ")S <br /> Inspection Date <br /> Sfi a�k�� c,A h5Ld3 <br /> Time In Time Out <br /> Business Rep Title i0 AM ''^^ 0 AM <br /> �1rC,�\c . S+f Ck(ArneAA ('n1A(1tjbC_ ` 5 u 0 PM 0 PM <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 /> ov 41 Active Q Passenger 0 Generator Q 0 dpor <br /> o <br /> PS Latitude Q Closed Q Altered <br /> G+ (V/� <br /> Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) _ftulzW <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 i Other F Ile. S�UJ Ck <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 <br /> 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> a <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 /> y1�S�_L �l SS�M p� An-� (31t` V k� T �C1'11 y [ �C► CA,1� <br /> Inspection Form Included: QI � ' <br /> Comments Included: ZdJ ��� ���� <br /> usinesse s Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:a Incorrect: KA � NJ EXAM 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L ® ■ <br />