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Waste Tire SG. ✓ey & Inspection Report Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1210 515 <br /> CalRecycle 181(Rev. (CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 5 - O Inspection Type(Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: Sctr Jd�(��,t r1 ��1i I 1�1 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 J Inspected By Inspector <br /> Physical Address 3 <br /> � 5205 <br /> Inspection Date 1 D / vX1l <br /> Time In Time Out <br /> Business Rep p Title y C { S O AM 0A1 <br /> ® <br /> PM � � 0 BPM <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 /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O 0 Closed 0 Altered N <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-use 0 Container <br /> Business Type(Fill all that apply) 1i <br /> 0 New Tire Dealer 0 Auto Repair it Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other &�_J A d?pn p l <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§4 <br /> 0 0 PRC§4 e Compliance Deadline <br /> 0 0 PRC§4 Wh�ta �� <br /> 0 0 14 CCR ® nts Date / <br /> CONSTR/rCT/ON SUPPLY m m m <br /> 0 0 14 CCR <br /> (Required for NOV or EX7 N <br /> 0 0 14 CCR WHITE CAP ®SCHEDULE <br /> 0 0 14 CCR STOLKTQN#23 CONTRA-5-06F- 017 NO <br /> 0 0 14 CCR iaulers 0 Referred/CalRecycle Enforcement <br /> 2 <br /> Lu <br /> 0 0 14 CCR phone: 209.944.9541 ities <br /> 0 0 14 CCR 1166 S.Wilson Way phone: 800.924.9541 )Generators <br /> Stockton,CA 95205 fax: 209.944.8154 ®In Compliance-No Violations o <br /> 0 0 Other:§ <br /> Comments - - - --�. "\� -- -- 1.I _ �1 -- <br /> in <br /> Nb O I(, ;�,s (� u11W <br /> Inspection Form Included: 0 <br /> �Comments Included: — - - <br /> Business Rep's Signature Phone Number Ins tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: N EXAM L E 2 13 1 <br /> 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Co y:L ® 0 <br />