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Oa Waste Tire Sui vey & Inspection Report <br />State of California <br />CalRecycle <br />CalRecycle 181 F®rl1'1 - Page 1 <br />Dept. of Resources Recycling and Recovery (CalRecycle) <br />Part A - Survey <br />Business ProfileTPI1 <br />c)- <br />Site h 1 <br />Site Suffix: V <br />Local <br />Identifier: SU n7UL4I' n <br />Q <br />Business or Facility Name <br />Mun�AM uc�i n <br />Physical Addrel <br />Business Rep( Title <br />f <br />Tire Count (Whole/PTE) <br />9 � <br />O <br />GPS Latitude <br />0 <br />Longitude <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair 40 Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />Inspection Report Number <br />I1 -1177607 <br />BLUE OR BLACK INK PEN <br />Inspection Details <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />31 - 1 01 Esc0-TTD <br />Inspection Date q / 1 9 / I 3 <br />Time In Time Out <br />' S Q ®PM ` V ®PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />Q Passenger <br />® Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />Q <br />Q <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />U Government U Retreader U Dismantler U Tire Derived Fuel <br />Q Collection Q Crumb Rubber <br />Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 -Tire Program ID Number from CalRecycle <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0101 <br />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CalRecycle Enforcement <br />® in Compliance - No Violations <br />Ir0A0W\('\4A WAS C)10 <br />fn ic)I!/��"�_ir1S_ bI CfefJls '_conCem), <br />Inspection Form Included: Q Met <br />t�aA <br />Comments Included: ® <br />Business Rep's Signature Phone Number <br />INSTRUCTIONS ON BACK I Correct:* Incorrect: <br />■ White Copy: CalRecycle Yellow Copy: Operator <br />Pink <br />`-'Phone Number <br />62081 <br />® ■ <br />CV <br />U) <br />0 <br />Lu <br />Lu <br />0 <br />