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Waste Tire purvey & Inspection Report Inspection Report Number <br /> Cal Rec cle State of California — <br /> Y CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1245195 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' /� l ' � ) �_ O [ Inspection Type(Fill one) <br /> Site Suffix: � (Q / r o Routine Q Re-inspection Q Referral Q Observation <br /> Local [� If Referral,choose referral type(Fill one) <br /> Identifier: _Jvceoi"n Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name I <br /> Inspected By Inspector <br /> Physical Addr ss <br /> Inspection Date ` V <br /> Tvcc �� C& 9 S 3 �� <br /> Time In Time Out <br /> Business Rep Title iAM O AM <br /> T&/( ` /{CLr3 *a'-L • O PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger 0 Generator O Outdoor IC <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude — Q Planned ® 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 Q Other p <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 /> -� Trac Biomass,an affiliate of <br /> reenleaf <br /> Q Q PRC§42953 Compliance Deadline <br /> G <br /> Q Q PRC§42956- POWER <br /> Q Q 14 CCR§1845! Date[:[] <br /> Q Q 14 CCR§1845! Tom Baker <br /> Q Q 14 CCR§1845! Purchasing/Planner (Required for NOV or EXE N <br /> 209.835.6914 office <br /> Q Q 14 CCR§1845! 209.879.6923 private line <br /> Q Q 14 CCR§1846, 209.834.6766 cell Q Referred/CalRecycle Enforcement <br /> 209-879-6924 fax w <br /> Q Q 14 CCR§1846 " tbaker@greenleaf-power.com <br /> Corporate He a 14800 W.Schulte Rd <br /> Q Q 14 CCR§1846: 2600 Capitol to 430 Tracy,Ca.95377 ators ®In Compliance-No Violations o <br /> Sacramento, 16 <br /> Q Q Other: <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: cze2 (!� C,�(J <br /> ess Reps Signature Phone Number Inspector's Signature P one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: JLJEJ 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA © 0 <br />