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City/County <br /> Waste Tire Survey and Inspection R" Mailing Address <br /> State of California �G?0. � ENIVIYDVJ" ve,�D, Ine u ber <br /> CIWMB-54 (10/03) WC, <br /> PART A—General Information/Survey •`�' c1 S�� Page Iof <br /> � a 1NSPEC7}OtVlTE1/1SIT1111�11111 1112! 1:51,11JI I— <br /> Type(check one): Enoutine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. <br /> Facility: ; SWIS: Inspecte by Time In: Dat `- Regulatory Status: <br /> File No TPID: y _O 4 /City ❑Permitted ®-.Excluded❑Exempt❑Unpermitted <br /> • Code Time Out: otal ime OperatfonaLStatus:, ,} >:,_ <br /> -- _ ❑State —- ;�Achve❑Closed❑Enactive❑_f?lanned:_: <br /> Local: s <br /> Business/Facility Name: Tire Coiinh,; Type: <br /> (Passenger❑Altered❑Truck❑OTR <br /> Addr Phone: Storage Type i . a <br /> 7 �� `t� l 6 7 7 j <br />