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Waste , ire SVey & Inspection . .Z orpl�pection Report Number <br /> CalRecycle <br /> State of California <br /> CalRecycle 181(Rev. y(CalRecycle) Survey <br /> Survey Form Page 1 <br /> 11 _ 1242442 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) _ p <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � 7 - o Inspection Type(Fill one) <br /> Site Suffix: s SP Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SQn ��M V�� 6Z) If <br /> Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name " �1 Inspected By Inspector <br /> hywas \1 0:5 GAC-SS <br /> Physical Address <br /> \,A ?OD <br /> Inspection Date C> -7 <br /> y <br /> C Ca Cv ClqS3 Time In Time Out <br /> Business Rep TitleO AM O AM <br /> S't�V2 ��w�t �inv i�ohw'fM� \ -3 C O PM 2 L S e PM <br /> C 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) 2, <br /> Active Q Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q 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 0 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§42� <br /> Q Q PRC§42� Compliance Deadline <br /> PRC§4Z Steven Howie P.E. <br /> Q Q 14 CCR§ Environmental Specialist Date m / Q / m <br /> Q Q 14CCR§ I� 11� IrrT I��I�,II� � � AC <br /> Q Q 14 CCR§ �� P U R F (Required for NOV or EX7) <br /> Q Q 14 CCR§ 14700 W.Schulte Rd o <br /> Tracy,CA 95377 <br /> Q Q 14 CCR§ phone+1209-836-8269 mobile+1209-321-4346 alers Q Referred/CalRecycle Enforcement W <br /> Q 0 14 CCR§ fax+1209-836-0707 IS <br /> steven.howieCa o-i.com ienerators <br /> Q Q 14 CCR§ �In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �C'�� onC� <br /> C�,5 �,cp cis car C'C>VVceC y'\ <br /> Inspection Form Included: Q <br /> r <br /> Comments Included: -qW_522 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:IS Incorrect: W �Xj A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />