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Waste Tire SL,. ,iey & Inspection Repoli Inspection Report Number <br /> State of California <br /> CIWMB 181 04tO4) <br /> 11 - 112 7 6 5 2 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey_. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: d 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: S&A -jQ 1k, n cwfi Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ldr�esesqiPhysical I - { Q ( f0116 <br /> � 6351 S. <br /> LAC C A 95-330Inspection Date / 1 0 <br /> Time In TimeOut <br /> Business Rep Title Jr—S ,(� ^ I � � O AM � � � 0 AM <br /> /� <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 /> ' O Active Q Passenger 0 Generator • Outdoor <br /> O 0 Closed Q Altered <br /> i^jp$ Latitude Q Hauler o Indoor <br /> O o Inactive * Truck <br /> Longitude - Q Planned Is OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader 0 Dismantler o Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Is Other lir,a <br /> - f- - - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> !0 Notice Of Violation 0 Extension <br /> 0 0 <br /> Q o F Lori U' s <br /> Compliance Deadline <br /> � <br /> 0 0 F 3 429 Office <br /> 0 0 1 luirements Date M / M / <br /> FF] <br /> O o 1 <br /> 0 0 1 AVays (Required for NOV or EXT) <br /> 0 0 , /llobi/L ANA9i«c - - <br /> The Storage& i Solution Specialists <br /> 0 0 1 �/� 2��'� to Tire Haulers 0 Referred/CIWMB Enforcement <br /> 16351 S.McKinley Avenue Xl <br /> O 0 1 Lathrop,CA 95330 office 209.858.9300 se Facilities _ <br /> O 0 1 www.mobilemini.com fax 209.858.9500 aste Tire Generators ` In Compliance - No Violations <br /> OO is lunites@mobilemini.com toll free 800.531.7253 <br /> , <br /> Comments 21 _ QSE%nA-rip.—A (3o4�t 1 <br /> 1` <br /> or CrtU5 of co.nO M <br /> �. Uci ; r U 'T' f ; 4, Lh <br /> Inspection FormIncluded: 0. X134 7 <br /> ,C17 <br /> Comments Included: 0 - <br /> in ss Rep's Signature Phone Number Insp or's Signature Phonber <br /> INSTRUCTIONS ON BACK Cl�orrect:o Incorrect: k �1 E XVC <br /> 1 ' L 3 62081 <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pin ® 0 <br />