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........... - - -------- <br /> ------ ------ -- <br /> ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CalRecycle State of California - 1176487 <br /> CalRecycle'181(Rev.10/10) <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> Business Profile Inspection Details <br /> — —1 <br /> Inspection Type(Fill one) <br /> TPID- C <br /> Site Suffix: 0 G Routine 0 Re-inspection 0 Referral 0 Observation <br /> If <br /> Referral, <br /> .choose <br /> L If Referral,choose referral type(Fill one) <br /> Local 0 Educational Visit 0 Other <br /> 0 CHIP 0 CalRecycle 0 Complaint <br /> Identifier: Sa C)I, , C)" <br /> Business orFacilityName NJ Inspected By Inspector <br /> — Q , <�� r _� Co�pll�nI I - � (31 &-nPhys�)A.dclress Ov <br /> Inspection Date <br /> c A Time In. Time Out 0 AM <br /> Business Rep Title 0 AM PM <br /> 6 PM <br /> Storage Type <br /> e 'Onal Status <br /> at' <br /> only) <br /> < -6p r 7 <br /> Operational Status Tire Type Business Role <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> dh , ""� <br /> Tire Count(Whole/PTE) Active 0 Passenger Generator Outdoor <br /> Business <br /> Role <br /> I that apply) <br /> ,ill 7a <br /> It t <br /> Generator <br /> 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> GPS Latitude <br /> r 0 0 inactive 0 Truck <br /> 0 End-Use Container <br /> Longitude 0 Planned OTR <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retr ader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 �S(%CuAkVXCtk <br /> S <br /> 0 7Exteni,, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -1 ENFORCEMENT <br /> Violation'ti 0 <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Compliance Deadline <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> S 'o <br /> 0 0 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 <br /> (Required for NOV or EX7) & <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Lo <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 :E <br /> Lu <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance-No Violations <br /> 0 0 ,Other:§ <br /> CommentsNYW-s ck'�A�nok <br /> 0C <br /> Inspection Form InGluded: 0 <br /> Comments Included: 'Phone Number <br /> B)ines�'s Signature Phone Number Inspec is Signature <br /> s Rep <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X/-�, E X A M <br /> /N <br /> ■ White Copy:CalRecycle Yellow Copy:operator Pink Cop <br />