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=Yo, Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> ClWM of California Survey Form - Page 1 I - 10 13 5 3 2 <br /> CIWMB 181(New 04led) <br /> California Integrated Waete Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile` Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f 3 4 Z. J ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cp � � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physi al Address 349 – /0 / 67F�� IQcs <br /> �z3 G (, LL_ - <br /> Inspection Date C1 / 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0P 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire CountW hole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ( ) 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that appy) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> O Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. r <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements .4 <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB u`" <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days . Jnr a <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 O <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> � p1 <br /> 014 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators shwa x � <br /> O 11O <br /> Other: § <br /> Comments <br /> I <br /> Inspection Form Included:01 <br /> Comments Included:0 — – <br /> Business Rep's Signature Phone Number in or Signature Phone Number_ <br /> INSTRUCTIONS ON BACK a( }l, �+ � 62081 <br /> ■ White Copy CNVMB Yellow Copy:Operator Pink Copy:LEA ® . <br /> C_1 IS 15 1 F_1 4, F_1 7 2 0 <br />