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Waste Tire Sup dey & Inspection Report Inspection Report Number ■ <br /> CalRecycle Cte of alRecycleltfornia 181(Rev.10/10) I1 - 1210538 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 `A ` '3 , � � © ` Inspection Type(Fill one) <br /> Site Suffix: "1 6 1 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r- If Referral,choose referral type(Fill one) <br /> Identifier: 50.h J C7(t-q �h CO'Zh' y Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> gN'aC'Y ��ow�asC, ,� - 1 cD t �� v <br /> Physical Address <br /> 1`l foo \33. <br /> 1 cC� C A -I 53,77 Inspection Date <br /> Time In Time Out <br /> Business RepC Title 2 O AM O AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) -7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 0 Active Q Passenger •Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 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) <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 0 Other �%We6- (..-_e_y'eC06C Pow <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 /> 0 PRC§42951 -Was TarcGB ass.an affiliate of <br /> Q Q PRC§42953-Coni reenleaf <br /> Compliance Deadline <br /> Q Q PRC§42956-Regi POWER <br /> Q Q 14 CCR§18459-F Date <br /> Q Q 14 CCR§18459.1 - Ron Sichau <br /> Q Q 14 CCR§18459.2.1 Plant Manager (Required for NOV orEX7) a <br /> 209.835.6914 office a <br /> Q Q 14 CCR§18459.3- 209.879.6921 private line <br /> Q Q 209.914.9220 cell <br /> 14 CCR§18460.2- 209.835.6918 fax Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§18461 -h Corporate He a rsichau@greenleaf-power.com w <br /> 14800 W.Schulte Rd <br /> Q Q 14 CCR§18462-h Sac amenitol 816 430 Tracy,Ca.95377 rs In Compliance-No Violations o <br /> Q Q Other:§ <br /> � z <br /> ,AC,o�_m�_mom�ents`e�_ ��� w�s� ��� •!�S P2_C�C�� r�Oy�G�� _ ` S !�'��� <br /> C n\A_C_4t_IZ'_Y\ <br /> Inspection Form Included: Qy <br /> Comments Included: r <br /> Business Rep's Signature Phone Number Inspe or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ® ■ <br />