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= Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ■ t lir <br /> State of California <br /> CNJMB 181(New Survey Form - Page 1 ( 6 . 10 1 3 6 3 3 <br /> California Integrated W-1.Managenage <br /> ment Board <br /> Part A-Sui BLUE OR BLACK INK PEN <br /> Business Profile — Inspection Details <br /> TPIO- Inspection Type (Fill one) <br /> Site Suffix: 3 7 00 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CLf2 OQ H CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 �LLygB�NiOf//� <br /> f G 95-330 Inspection Date <br /> Time In Time Out <br /> Business Rep Title [ 0 AM <br /> ) 7 AM <br /> O D D O PM 0 PM <br /> - <br /> - - o- -—Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) ' (Fib one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude TO Hauler 0 Indoor <br /> O0 Inactive 0 TruckLongitude - 0 Planned 0 OTR End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tlre Dealer 41 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 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. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 14 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 <br /> 0 0 Other: § <br /> Comments )Cajc.�-�-J- 44.4 <br /> v,ezcleoe ANY All .41, AC <br /> ! ' <br /> 3 r ir, A,,vy v,40644 P.? <br /> Inspection Form Included:0 /J ��V� 7 � <br /> -#¢�� — 777 <br /> I Comments Included: <br /> I!— Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IE XA M PIS, - T1213, 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy..LEA ® ■ <br /> 0619404.01054 <br />