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FROM :CALAVERAS GARAGE FA;; NO. :209-464-5126 Dec. 23 2004 10:47AM P2 <br /> �•, ENV1R0NMEN'1,.L inspectidn Report Inspection Report Number <br /> HEALTH DEPARTMENT <br /> SAN JO . UIN COUNTY Form Page 1 7 1 .01 4 7 6 Q <br /> BLUE OR BLACK INK PEN <br /> GAR TT BACKUS <br /> Environmental Hetdth Speciatiat Inspection Type (Fill one) <br /> t2W)468-2986 304 E.Wclwf Avenuc.3rd I•loor J 0 Routine Q Re-inspection Q Referral Q Observation <br /> FAX(209)468-8392 Sto&ion-CA 95202-2708 <br /> 6msil:gbalckus'#-�sjechd.com hupl/w%.w.co..,an-ii)Uauin.r:.uvehd If Referral,choose referral type(Fill one) <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam® 1' Inspected By -—— Inspector <br /> r^ <br /> Physical Address <br /> Sweet <br /> Inspection Data 1 . <br /> ` Time In Time Out <br /> ",,ty tare rP code .I' <br /> Business Rep Title + EE :, <br /> 0 PM m 0 AM <br /> PM <br /> Operadonal Status Business Role <br /> (Fill one only) (Fill all that apply) <br /> 1 1 ®Active ®Generator <br /> r-- <br /> , <br /> Closed <br /> GPS Latitude Q Hauler <br /> Q Inactive <br /> O <br /> Longitude Q Planned Q End-Use <br /> 4 <br /> Q New Tire Dealer ®Auto Repair Q Trucking Fleet Government Q Retreader Q 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 i <br /> Part B Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility <br /> V;�'.,A .•� !U1,.t[!IG;AND�pAA�VIF�ST.REQU1..,: .�, •, �; - � �- �� <br /> Q Q PRC§42851•-Waste Tire Hauler Registration and Transport of Tires <br /> I•Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> PRC§42956-Registration/Decal in Vehicle <br /> !IQ O 14 CCR§ 18459 -Responsible Entities Complying with tssting Requirements <br /> !Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB s <br /> IQ Q 14 CCR§18459.2.1-Submittal of ManJest Forms and Tir6 Trip Logs within 90 days <br /> f/ ti <br /> IQ Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requiromcnts for Registered Waste Tire Haulers v q sdh ^��� 1i�oi eotw <br /> O O. 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ` <br /> Q ® 14 CCR§18462-Manlfest System Requirements for Tire De�Iers oWaste Tire Generators <br /> , <br /> Q Q Other. § _` _ _ x ay - ��•. <br /> Comments <br /> ,--4 <br /> , , 62081 <br /> INSTRUCTIONS ON BACK Correct ® Ihcaerec E:X A M P,,L E I I,2 3 <br /> j wnde COPY CIWMB YCNIUw COPY Operator Pink C:OPY:LEA — <br /> i <br />