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es4. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfornia <br /> CIWMB Waste <br /> nage Survey Form - Page 1 1 7 - 1 0 2 5 7 5 3 <br /> California Integrated waste 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: l - 9 7 l lip Routine Q Re-inspection Q Referral Q Observation I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector5a4l <br /> ew <br /> Physical dress <br /> -�G y Inspection Date 63 <br /> YTime In Time Out <br /> Business Rep Title O AM _ O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f # Active Q Passenger ®Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> Q Q Inactive Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair 0 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 <br /> Part B - inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility BINIT 8TATUS�__ <br /> a 't:��►€- HA.tJ)«![�GiY 1�i� ►l!�f���T�E��tEltl�k�[4tE j`5 <br /> OCaNtn9ptllt�attrikOef YiQiatlloan: <br /> Q Extension i <br /> 0 PRC§429; 1'n iAdllO O PRC <br /> O <br /> Q PRC§429', r-©, , <br /> Q O 14 CCR§ 1 u pets m / <br /> 14 CCR§ 1 •�-v� , (, P 7 <br /> LE_ <br /> O O 6;Z <br /> O Olife.. <br /> f qulreti:lw_tipV or� <br /> Q O 14 CCR§1 Ingredients for life ys _ . <br /> 14 CCR§ 1 .& <br /> Q O 14 CCR§1 ulersrCgritont ; <br /> O O 14 CCR§1 3S <br /> =F Sfit.,,ki•.s..e;: i`r'is<�:i�.i•:. =:: _ _ <br /> O O 14 CCR§1 enerators ' <br /> 010 Other. <br /> § �/ 1L is a -c`.•. <br /> Comments �/[ / �� l�Gir /Gtr �L! �f� - c-. /!�l'� O! �� W�`�J ���• -- <br /> �XJG�/D�'t?r oi` �!'G«�j ofi- �(/ ate.-�'►– •!/ <br /> ae./i� �,�ls ��- ri /�!/,s � t�.�c <br /> � � i' � r�✓`�-;?4c <br /> -- -- -- <br /> 000, <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> us n ss Rep's Signature Phone Number pe s Signa Phone Number <br /> INSTRUCTIONS O ACK Er fM1R � '` t�tr ( �� �X rt#': �` �ii._ t f� 3 62081 <br /> White Copy:CIWMB Yellow Copy,Operator Pink Copy:LFA8 <br />