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Waste Tire SuRey & Inspection Reporolnspection ReporrNumber <br />CalRecycle State of California I 1 —1210393 <br />CalRecycle 161 (Rev. (CalRecycle)Survey <br />Survey Form - Page 1 <br />Dept. of Resources Recycling and Recovery(CalRecycle) <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />V <br />A <br />Inspection Details <br />TPID - <br />Site Suffix: � � <br />� _ <br />� � <br />O � <br />Inspection Type (Fill one) <br />§ Ph: -(209) 239-8111 <br />14 CCR § 18 M1 LCell: (209) 456-2383 <br />* Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br />Local <br />Identifier:Sq h 3'a Q el CO, <br />bb <br />Q <br />Q <br />Business or Facility Name <br />Q <br />O <br />Inspected By Inspector <br />Zwl�ecb�\ <br />I Ftepalrd, , <br />Transmission gses and All Kind-f6f,Miri r <br />, <br />ATT , <br />Physic I Address <br />rs <br />14 CCR § 18 U t Re ccions Apply►; <br />O <br />C1 I �d, <br />14 CCR § 18 2142 W. Yos, �fn e! Ave. Manteca, A 95~ <br />Q <br />Q <br />14 CCR § 18 aerators <br />010 <br />Other: § <br />Inspection Date 5 6 / L 3 <br />Time In Time Out <br />Business Rep <br />Title <br />UO AM O AM <br />' <br />� <br />�lacs 'nJ c� i %� <br />ala <br />1?,( <br />� PM 1 v IS PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />Z <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />i Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />® Generator <br />Q Hauler <br />0 Outdoor <br />Q Indoor <br />GPS Latitude <br />O <br />O <br />Q Inactive <br />0 Truck <br />Longitude — <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />• New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder 8 Other �Jj� <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />PRC § 42951 <br />PRC § 4295 ��� ypE��_A� Manjeet Singh <br />PRC 4295E <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />Q <br />§ Ph: -(209) 239-8111 <br />14 CCR § 18 M1 LCell: (209) 456-2383 <br />7RUCKTRAILER.IMB ANDA-, Fax: (+(209) 23"- 9 ft <br />Q <br />Q <br />Q <br />Q <br />14 CCR § 18 � .=tet +. <br />14 CCR § 18 Engine Overhaul Tune Up Elecf�onlc-Diaggnosis • Tlees <br />APU <br />Q <br />O <br />Rear End Oil CWiige Brak@s,�nstalLNew <br />14 CCR § 18 Reefer Repair Welding RV Wash Cl utchAAl;erttat4rs <br />I Ftepalrd, , <br />Transmission gses and All Kind-f6f,Miri r <br />, <br />Q <br />Q <br />rs <br />14 CCR § 18 U t Re ccions Apply►; <br />O <br />O <br />14 CCR § 18 2142 W. Yos, �fn e! Ave. Manteca, A 95~ <br />Q <br />Q <br />14 CCR § 18 aerators <br />010 <br />Other: § <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />(Required for NOV or EX7) <br />Q Referred / CalRecycle Enforcement <br />* In Compliance - No Violations <br />Comments t_ � ynSp�Cil oa � zS �� a^ <br />/� <br />1. 1 to <F t n N n,� <br />Inspection Form Included: <br />Comments Included: 40 <br />Business <br />D's Signature Phone Number <br />_q6g-32a4 <br />Phone Number <br />INSTRUCTIONS ON BACK I Correct:�]j <br />62081 Incorrect: E X A M P L E 1 2 3 <br />® White Copy: CalRecycle Yellow Copy: Operator Pink Copy: LEA <br />