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Waste Tire S- rey & Inspection Repot <br />••■.u. StateofCalifornia <br />CIWMB183 (NewO4/04) Comments Form <br />California Integrated Waste Management Board <br />�� SURVEY REQUIRED) ■ <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID -Inspection <br />Site Suffix: ( Q S� 7j <br />Report <br />Number: <br />I I — 1 Z �7 <br />Inspection Number on the associated Survey form (Page 1) <br />Comments <br />Z - iso l-ti11 'lYl `� C�,�i:,y <br />Q-- • �Y' -�C:�-�- <br />■jeXjAMjPEJT 2 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />42408 <br />■ <br />