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02 Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1176772 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Surve fesBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � ^ Q � 1 ► I _ � � Inspection Type(Fill one) <br /> Site Suffix: c l� 4 Routine Q Re-inspection Q Referral Q Observation <br /> Local �- ( � �— If Referral,choose referral type(Fill one) <br /> Identifier: � O', Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> J <br /> Business or Facility.Name t Inspected By Inspector <br /> Stn r � -z� - l <br /> Physical Address 0 E� <br /> �oU��u r. C Inspection Date l <br /> Time In Time Out 1) <br /> Business Rep Title \ O AM n O AM <br /> Q- ' 1 0 WPM � 3 V 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Is Closed Q Altered A JpJ It� <br /> GPS Latitude Q Hauler Q Indoor <br /> Q 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 4k Other 1�� <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§429 <br /> Q Q PRC§429 11 �9J35� s 5�3 Compliance Deadline <br /> Q Q PRC§429 Re \A <br /> Q Q 14 CCR§' `ham �� Date m m / m <br /> Q O 14 CCR§' Nancy Estrada <br /> Q Q 14 CCR§ Sales&Office Coordinator (Required for NOV or EXE N <br /> r <br /> Q Q 14CCR§1 0 <br /> 1250 S.Wilson Way,Suite 202,Stockton,CA 95205 F <br /> Q O 14 CCR§1 T. 209.465.0177 hers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§1 F: 209.465.0183 s w <br /> 14 CCR E: nancy.estrada@shredit.com <br /> Q Q §1 W: shredit.com enerators ®In Compliance-No Violations o <br /> Q Q Other:§ \\ L <br /> Comments Ale- <br /> 61 <br /> 65 u jos CTf C0f) M, <br /> Inspection Form Included: Q ,J/ nO <br /> Comments Included: `�"' -- -- ---3_�_L_O <br /> Business Rep's Signature Phone Number Inspe is Signature gone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />