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09255050084 <br />Waste Tire- Survey & Inspection Report. Inspection. Report Number <br />1a State of California <br />CIWMB 181(e) Survey Form - Page 1 I1. - 1141171 <br />Californiaa Integrated Waste Manage <br />Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -inspection <br />Site Suffix: <br />X A P L 1112F31- <br />51:916156] <br />White Cop CIW <br />Yelloperator. <br />Pink Copy. LEA. <br />®, <br />Type (Fill one) <br />l <br />Q Routine ® Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local <br />Identifier: <br />% <br />��� 'In <br />M u <br />CHP Q CIWMB Q Complaint Q Educational Visit Q.Other <br />Business or FacilityName <br />L.��o Cor ri�'1 I <br />Inspected By Inspector <br />_�el� <br />Physical Address <br />r_- ll <br />I �� L-�11 � <br />11 <br />L��QD__�._._'=lu►'�(�� I ZtJ_. s}!?,-� I <br />— —" <br />�� <br />Stirel I <br />Inspection Date <br />t� _L__ - <br />\ Com. gJra aj <br />11 <br />-k.C-' <br />City Mate 2! Coda <br />Business Rep Title <br />Time In Time Out <br />®AM r�/0 AM <br />IO PM iLV .� l,� 0 P <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) i <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />r <br />• Active <br />Q Closed <br />Q Passenger <br />Q Altered <br />- <br />0 Generator <br />Q Hauler <br />(a Outdoor <br />Q indoor. <br />Latitude I <br />j I i ( O <br />• <br />��__ D <br />Longitude — I I `, I I I I 1 <br />Q Inactive <br />Q Planned <br />® Truck <br />I Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair. ® Trucking Fleet -.Q Government Q Retreader • O 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 1 1 <br />Part <br />B -Inspection <br />of Waste Tire Dealer, Generator, Hauler.and End -Use FacilityENFORCE <br />N 'STATUS <br />'V <br />Ai ,HAULING <br />AND IIAi4NIFEST RECIUIREMENTS F -, ""P% <br />