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� Waste Tir, Seumey & Inspection Repo"Inspection Report Number <br /> � <br /> CalRecycle State of California <br /> CalRecycle 181(Rev.10/10) 11 - 117 6 3 9 8 <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- ` � r� � � Cj � - O 1 Inspection Type(Fill one) <br /> Site Suffix: l U 1 I 11 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sin J�1�,�1 rX Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I 1"1 l J Inspected By Inspector <br /> �,Cn��C�t7S SkOc�bn �l�inl'c�nce. S�r�k►�� � 1 - I V � � 'n�'n <br /> Physical Address <br /> S <br /> a S��'� Inspection Date / <br /> Time In Time Out <br /> Business Rep Title <br /> 0 AM 0 AM <br /> a5 QPM `' QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> � � I ' Active 0 Passenger 46 Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 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 ® 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 0 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 /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q ® 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �xk, , (� lJ�U�J `fes \ r <br /> Inspection Form Included: Ql c <br /> Comments Included. ® Business Rep's Si re Phone Number Ins <br /> 9 ctor's Signature Phone Number <br /> 2nk <br /> 6zos1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect:White Copy:CalRecycle Yellow Copy:Operator Co y:L <br />