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Jul . 11. 2013 02 :28 PM HCI-7MAN BROS 209 `6 0749 PAGE . 6/ 6 <br /> I=' J.— LJL-VL Vn DLAVof\ INN VtN <br /> 7�77 7'wf;—v -vR <br /> % ­777 <br /> ? f. <br /> ........... izj; <br /> TPID- <br /> Site Suffix: Inspection Type(Fill one) <br /> Routine 0 Ra-inspection Q Referral 0 Observation <br /> .......... <br /> Local If Referral,choose referral type(Fill on®) <br /> Identifier: <br /> .........- 0 CHP 0 Ca]Reoyc4e 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector' <br /> 'physical Address <br /> C' <br /> ­"I_\�..0. ........ <br /> 3 <br /> Inspection Date <br /> 2- <br /> ............ <br /> Time In Time out <br /> Business Rep Title AM 4)AM <br /> C-) 0 PM <br /> 0 PV. <br /> A C, <br /> K. <br /> gqi� nyymz:M..� Business Role <br /> ft t�: status <br /> (Fill one only) jso'., (Fill all that apply) <br /> It Active Generator <br /> .......... <br /> Latitude 0 Closed <br /> GPS <br /> 0 Hauler <br /> ................ <br /> 0 Inactive <br /> .......... ..... <br /> Longitude <br /> 0 Planned Ed-U,, <br /> ........... ................. <br /> ............ <br /> ............ <br /> 0 Tire Derived Fu <br /> 0 Now Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader Dismantlar el <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler Agriculture 0 Shredder 0 Other <br /> Part B - inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF0RQEME_N __ <br /> STATIA, <br /> ..A HAULING ANP MANIFEi T REQUIRWENTS <br /> ....... 0 NOtIC6 Of Violation 0 Extehsion <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRO§42953-Contracts with Registered Waste Tire Haulers. Oomplence Deadline <br /> C) 0 PRO§42956-Registration/Decal In Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Ddt.� <br /> 0 () 14 OCR§18459.1 -The Program ID Number from CalRecycle 1 !' �. m ' <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days " qij1r*d.&r t4o V.L 0'r• <br /> I. <br /> 0 0 14 COR§18459.3-Retention of Comprehensive Trip Logo for 3 years <br /> 0 () 14 OCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred Calkocycle Enforcement <br /> 0 0 14 OCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Il1.In.Com0Uana*%-No Viol.altlO no <br /> Comments <br /> V <br /> J e- Ir <br /> ........... .......... <br /> t"tifi, <br /> .......... <br /> LIE, '"ARM <br /> ct. � ��_ :p•..a:r.r_."' . r �a -r,:••. 62081 <br /> INSTRUCTIONS ON BACK �.Corre Incorrea- [E X •A W=1fl 1 2 3 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br /> Received Time Jul, 11, 2013 2: 25PM No, 0721 <br /> .... .......... <br />