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Waste Tire S ey & Inspection ReporLIPlnspection Report Number <br /> State of California <br /> CalRecycle 11 - 1242424 <br /> CalRecycle 181(Rev.ry y(Calal Survey Form - Page 1 <br /> Dept.of Resources Recycling and RecoveRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � e O � Inspection Type(Fill one) <br /> Site Suffix: ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �DO� Y,\ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> VS "C1IzvC14' �1 1nV,e 'N a _ 1 <br /> Physical Address 3 1 C) 1 <br /> CJS °l53 37 Inspection Date ® 7 / O 1 / <br /> Time In Time Out <br /> Business Rep Title 0 AM Q AM <br /> l.Jl.0.Vhd�.C` t't�SSO��Y� G. .©• t \A C) • PM � � � a 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 ® Passenger • Generator ® Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler � Indoor <br /> O Q Inactive ® Truck - <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type(Fill all that apply) <br /> ® New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q service station Q Hauler Q Agriculture Q Shredder Q 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 /> O Notice Of Violation Q Extension <br /> Q Q PRI <br /> O O PR' Compliance Deadline <br /> O O PRI If S TRUCK AlIGNMENT <br /> OO 14 BEST DEAL IN TOWN cements Date m / � / m <br /> 0 0O O 14 14 <br /> TRUCK ALIGNMENT ONLY $99 vS <br /> (Required for NOV or EXT) <br /> O O 14 NEW, USED, RECAP TIRES <br /> Q O 14G OPEN 7 DAYS WEEK PH'(209)518-7839 Tire Haulers 0Referred/CalRecycle Enforcement w <br /> Q O 14? 2072 W YOSEMITE AVE <br /> _JK CA TEU Opp NVI/,y 120 Facilities <br /> Q O 14 — . F' a Tire Generators <br /> ��►`e!TECA 95337 0 <br /> I In Compliance-No Violations o <br /> O 1 O 1otr" <br /> .`Comments <br /> Inspection Form Included: Q <br /> Comments Included. <br /> iness p's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS-ON BACK Correct:® Incorrect: X � IV I <br /> IEIXIAIMIPILIEI 1112 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />