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Waste Tire Survey & Inspection Report Inspection Report Number <br /> cle State of California <br /> CalRecycle CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1242266 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + kA � � r 15 � _ O � Inspection Type(Fill one) <br /> Site Suffix: 1 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S0. �pCL�U�Y� ��Y� O CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date O 1 `� 1 <br /> CAS O�53210 ✓ <br /> Time In Time Out <br /> Business Rep Title0 AM O AM <br /> *^ \ 1 1 O O PM 2 ' ® ® • PM <br /> Coc� 1"Deur ��o�rr�C C. <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 /> * Active Q Passenger ! Generator •Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned 0 OTR O 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 FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q O PRC§4, <br /> Q Q PRC§42 Cart Means Compliance Deadline <br /> PLANT MANAGER <br /> PRC§42- <br /> 0 Q 14 CCR f Its Date <br /> Q Q 14 CCR <br /> O O 14 CCR AMG RESOURCES (Required forNOVorEXTJ <br /> Q Q 14 CCR E o <br /> Q Q 14 CCR? 15332 S.McKinley Ave. aulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> 14 CCR E P.O.Box 442 Lathrop,CA 95330 lies <br /> Q Q m <br /> 1 209.858.2458 M 209.617.0068 F 877.458.4744 <br /> Q O 14 CCR E cmeans@amgresources.com Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments ` N!L\WP_ . _0A hhne enP^ ^NIN—SS &P-& <br /> CIL <br /> —car. c7 eM <br /> Inspection Form Included: Q <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspec or'�ignt.r, <br /> Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L E 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />