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■ 02 Waste Tire Su, Bey & Inspection Reporn Inspection Report Number ■ <br /> CalRecycle State of California 11 - 1196527 <br /> CalRecycle 181(Rev. (Cal Survey Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> F' 'A-Survey BLUE OR BLACK INK PEN <br /> less Profile Inspection Details <br /> TPID- 5 / g � - Inspection Type(Fill one) <br /> Site Suffix: (7 l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5;ah �OQ-G Vey V Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name {� Inspected B Inspector <br /> P Y P <br /> Physical Address 6 <br /> U oL� S w, C�ove(- V4_ <br /> C0. <br /> CIN Inspection Date 2 6 3 <br /> Time In Time Out <br /> ep Title <br /> Business c • AM I AM <br /> O J 0 PM I I ' ' C) O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) (`Q <br /> Q Active Q Passcepger Q Generator Q Outdoor <br /> GPS Latitude 0 Closed Q Altered� Ha N C� <br /> Q Hauler Q Indoor <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 /> dew Tire Dealer Q 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 • 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§4295' <br /> Q Q PRC§4295: Compliance Deadline <br /> PRC§42951 <br /> Q Q 14 CCR§1E ( ,a 4` irements Date <br /> M / <br /> m / m <br /> Q Q 14 CCR§1E ^v- <br /> Q Q 14 CCR§1E ...S�Z�� hCG tr i ✓s (Required for NOV or EXTj N <br /> Q Q 14 CCR§1E \\ <br /> Q Q 14 CCR§1E �` hGa e�T�ve �'� Tire Haulers Q Referred/CalRecycle Enforcement <br /> Q Q 14 CCR§1E :Facilities w <br /> Q Q 14 CCR§1E �S to Tire Generators <br /> In Compliance-No Violations o <br /> Q Q Other:§ <br /> Comments �U`+.,nom v3�►-�1�'G� ����- �\`�-S��C?�`�`'�� C�`f�—��A.�/�� �. <br /> o �h O�aOy�S CC <br /> No `C�•�5 S:1 R -�S o` <br /> eCa acct�,,`�,r�cs5�5_ \�aS _ h:c�s v ev�� .c�-� wS a •��wvhwe M D Cl <br /> ,„spection Form Included: QCA&q <br /> Comments Included: Q ��� p�(/ 2oa-X162-32t <br /> Business Rep's ignature Phon N ber � Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:• Incorrect: L ',E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA © 0 <br />