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Waste Tire gunp Repb,, :ection Report Number. <br /> & Insection Re c�� <br /> CalRec cle State of California — <br /> Y CalRecycle-181(Rev.10/10) I1 1245355 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Q Inspection Type(Fill one) <br /> Site Suffix: ` J J ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: X n To 6 Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> 14-foo W , hv1 l 44 <br /> _ Inspection Date <br /> 1 Vim_ , - S 374 �✓ <br /> Time In Time Out <br /> Business Rep Title S® PM WPM—O AM Z �j O AM <br /> � ✓ ✓ � <br /> ,r i Ct r-\ F67 nnl C�,K5�/ha,-J <br /> 4 <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountOI /PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 07 ® Active Q Passenger a Generator Q Outdoor <br /> O 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 ® Other & -S Auto <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 <br /> Q Q PRC ^ Compliance Deadline <br /> PRC <br /> Q Q 14 C( nents Date m <br /> Q Q 14 C( <br /> Q Q 14 CC (Required for NOV or EXT) N <br /> a <br /> O Q 14 C( BRYAN A FONG <br /> 0 <br /> Q Q 14 CC GHD 5900 Hollis Street Suite A Emeryville �,A 94608 USA =Haulers Q Referred/CalRecycle Enforcement <br /> T 510 420 0700 M 510 385 0509 w <br /> Q Q 14 CC E bryan.fong@ghd.com W www.ghd.com cilities <br /> Q Q 14 C( 'ire Generators <br /> WATER I ENERGY 8 RESOURCES'ENVIRONMENT I PROPERTY 8 BUILDINGS I TRANSPORTATION �In Compliance-No Violations o <br /> Q Q Other B <br /> Comments <br /> c "- L _ <br /> Inspection Form Included: Q 11 ��o�y20— ZlX <br /> 3309 <br /> Comments Included: <br /> Bu ne Is Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: IEIXIAIMIPILIEI 1112 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA ® 0 <br />