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Waste Tire Su,vey & Inspection Report Inspection Report Number <br /> State of California <br /> CalRecycle I 1 1242499 <br /> CalRecycle 181(Rev.10/10) <br /> (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection_ l Inspection Type(Fill one) <br /> Site Suffix: N7J J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S CA<) JOA u n �Im 1111 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 1 Inspected By Inspector <br /> Physical Addr s 1 l ( cs�0^�"'�� <br /> sow ��� ` <br /> Seo&'�Or\ <br /> � �C r�5 Inspection Date � / j�J J C•v Time In Time Out <br /> Business Rep Title <br /> AM 10 AM <br /> �7� �h 1 Q _ 3 5 Q PM I 1 O 0 PM <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 Q Outdoor <br /> N <br /> Q Closed Q Altered • / <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) 1�f <br /> Q New Tire Dealer Q Auto Repair ® 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 ® 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§429 <br /> Q Q PRC§429 Compliance Deadline <br /> Q Q PRC§429 <br /> Q Q 14 CCR§- uirements Date E[1 / 1:11 / m <br /> Q Q 14 CCR§' 1 r' lays (Required for NOV or E)CT) <br /> 0 N <br /> Q Q 14CCR§1 <br /> Q Q 14 CCR§1 e Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q Q 14 CCR§1 ;e Facilities w <br /> Q O 14 CCR§1 Ste Tire Generators <br /> In Compliance-No Violations o <br /> 01 Q 1 Other:§ �] l L l_ <br /> Comments n 1/1}U��)G ��rc. 1 f�S� /�] �Lini' ,LC JGL1 C rw�r/� Y 4ollL'W��lGy <br /> No y'0\a" vis of c.,r(,u s th iA)-#)tun <br /> Inspection Form Included: Q _ �/� ([ R <br /> Comments Included: ® �tor's <br /> "`'4��� p����"Business Rep's Signature Phone Number Inpignature Phone Number <br /> INSTRUCTIONS ON BACK [Correct: Incorrect: X4­q E X A M P E 1 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:L <br />