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Waste Tire Su grey & Inspection Report inspection Report Number ■ <br /> CalRecycle State of California — <br /> CalRecycle 181(Rev.10/10) Survey Form - Page 1 I1 1230170 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U 6 - 01 <br /> ® Inspection Type(Fill one) <br /> Site Suffix: _l * Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q„ ry %41%rN v�k-%-/ Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addre s <br /> sog <br /> sko6C� ^5033 Inspection Date { ® / 30 <br /> Time In Time Out <br /> Business Rep Title O AM tS O AM S PM '1 -7 * 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 /> 1 1 Q Active Q Passenger Q Generator Q Outdoor <br /> OClosed Q Alte /A` .4 <br /> GPS Latitude • Q Ha-uF�F� Q In oor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <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 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 /> ' - T Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Wast---- <br /> Q Q PRC§42953-Cont Compliance Deadline <br /> Q Q PRC§42956-Regi; Keep On Trucking Company <br /> Q Q 14 CCR§18459-R John Little Date m / m / m <br /> Q Q 14 CCR§18459.1 - General Manager Q <br /> Q Q 14 CCR§18459.2.1 (Required for NOV or Exr) <br /> 18459.3- 705 Cavanaugh <br /> 14 CCR <br /> Q Q § Rough&Ready Island F <br /> Q Q 14 CCR§18460.2- Stockton,California 95203 <br /> (800)666-5337 Q Referred/CalRecycle Enforcement w <br /> Q Q 14 CCR§18461 -M (209)938-0750 Ext.2202 <br /> (209)465-0720 Fax <br /> Q Q 14 CCR§18462-M 649-2973 Cell <br /> E-ma 1.little@kot.om In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments 04 <br /> "�:�•�. ttAyJ�r�Q WQ_C Iqo� ` /!�� �iO�-Q.��Qti-S dC' ,��Q� CAyl.C2r✓� <br /> NC�'tc5�� �� ���,��V'P��5 Y�(' ����Cl�� ��� -�t��Q'�ti r•�Y1. �CO V►�.h,..4.1� <br /> Inspection Form Included: Q �� Sj <br /> C ( Q C.o <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number ?pJct.r's Signature Phone Number <br /> �-,( 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X NJ EXAMPLE 1 2 3 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © ■ <br />