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REr - 3`,/ED <br />DEC 2 9 2005 <br />; 0 � N06 <br />SAN JOAQU(N COUNTY ENV! R ON M E N 1- H EAPI H <br />OFFICE OFEMEI Y PERMIT/SERVICES <br />Waste Tire Survey & Inspection Report Inspection Report Number <br />•f�� solo of catllornlo <br />CIwMB tat (NOW Doled► Survey Form -Page 1 14. -.10068 <br />.. ._00 <br />cowa"wil"uarrlidW"J*11"nall6 "nteoaro BLUE OR BLACK INK PEN <br />Part A - Surv_e —.... -- <br />Business Profile inspection Detills <br />Inspection Type (Fill one) _... <br />TPID -- <br />Sib Suffix: ° W 3 0 $ : O ' is Routine Q Re -inspection Q Referral Q Observation <br />Local � It Referral, choose referral type (Fill one) <br />Identifier. C..J�� (� u4r. C Q CHp Q CIWMe Q Complaint Q Educational Visit Q Other <br />I <br />-�— ` <br />Business or Facility Name n Inspected By Inspector <br />�l,A.�n�e+ #n, JPS'Vices i - - <br />3 Physical Address �t; <br />Business Rep <br />�Ibe►�ta iPodv�_�•e�. <br />Tire Count (Wholetil <br />GPS Latitude <br />gsals <br />Title <br />Inspection Date (J ' <br />Time In <br />0 AM <br />M <br />(ZL" r - <br />' .. Operational Status <br />` (Fill one only) <br />JL 4D Active <br />O Q Closed <br />O Q Inactive <br />Longitude _ Q Planned <br />Business Type (Fill all that apply) <br />Q New Tire oerlor Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Tire Type <br />(Flo all that appt <br />Q Passenger <br />Q Altered <br />49 Truck <br />Q OTR <br />. 3`0 l o 5 <br />Time Out <br />O <br />3 <br />Z; O AM <br />✓; DPM <br />Business Role <br />storage Type <br />(Fill all that apply) <br />.(Fill all that apply) <br />• Generator <br />Q Outdoor <br />Q Hauler <br />Q Indoor <br />Q End -Use <br />fa Container <br />Q Government Q Ratreader Q Dismantler <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tlres <br />Q PRC § 42953 - Contracts with Regatared Waste Tire Haulers. <br />Q PRC § 42956 - RegistrationlDeeal In Vehicle <br />O 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q 14 CCR § 18459,1 (a) (b) (c) - The Program ID Number from CIWMB <br />Q 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Other § <br />Q Tire Derived Fuel <br />art f ernagCw firaVer Rept <br />Comments �C. 1:._ _ /t,Ls t:if6ok, � aiLr( � Ta it o wl was nnt4C� <br />jus_ htf {IMS ,iwvtoes-in�rNl'10� f m Jar' C�(s �+�I�-s <br />Y - <br />1►' h Ne •� h ta> � (BccN <br />00. Us an ol—was�i-e <br />r Ved ,{rcm _ �-✓•ta-ii ler-s Tpr - boA aNw.e- and _-,B JZP in'! <br />*e.S ctrf_._._.. <br />►ec�iAhs _ rh <br />Inspection Form Inciuded: Q \jju� , cF r- <br />('' 6 <br />Comments Includes(; -- "\��` -L- L/ fa <br />Phone <br />_ Business Rep's signet Phone. Number I ctor's tura J Phone Number .. <br />INSTRUCTIONS ON BACK ;} I IIII�F ' " E XIt;�ih P rL E 111,0 <br />62081 <br />While Copy: CIWMB Yellow Copy: Operdlor Pink Copy: LEA <br />TO 39Vd H.L-W3H-V.LN3WN021IAN3 BET0091; 6Z:91 S00Z/6Z/ZT <br />