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City/ un Waste 1 lix c Survey and Inspection Report Mailing Address Phone Number State of California 54(10/03) � 5dD� 53-7618 Page of PART � PART A–General Information/Survey '3-` ,'tJ�)S INSPECTtONiTE-V1SiT 777 (checkRoutine ❑Re-inspection ❑Complaint ❑Observation ❑ CIWMB Referral El CHP Referral Other. Inspect_ by. Time In: Date: ` Regulatory Status: n (City - ❑ Permitted [R-Excluded❑ Exempt❑Unpermitted , ,a--D "yCode Time Out: To al ime. -Operational Status_❑State __-_ ®Active O Closed❑Inactive❑ Business/Facility Name: Tire Count:-;, Type: L rJ ❑Passenger❑Altered❑Truck El OTR �CQ-1 rStora eT f ��:�. � -,: Address: Phone: _�, $J_Outd®_Indoor❑Confaiuter t D .,,. Inspector(Please P.-no. Business Rep: Ow er:1_ n � �— Title: ri J� /t/lA� r 1 'i1JE✓ Role ofBusiness:.(Check auttntapply) yr :. Facility Typef`(check one) ❑ Major WTF(>5.00C^es) < ❑ Minor WTF(,Soo ares) C3Waste Tire Location Osco crest 0 Generator ElHauler ElEnd-use Business Type:(check an not aPPfY 7 .., Tire Dealer ❑ Retreader ❑Dismantler ❑ Auto Repair ❑Auto Body ❑Car Dealer ❑Collection LJ Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑Other:Describe Excluded Business Types(checkonytf4pr�caeie). - [�- 14 CCR§ 18420(a)(3)-Facilities storing less than 500•waste tires(Waste Tire Location). ❑ 14 CCR§ 18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises. ❑ 14 CCR§ 18420(a)(6)-Auto dismantler storing no mc'e than 1,500 waste tires for less than 90 days. [D� 14 CCR§ 18420(a)(7)8(e)-Tire dealer storng no more than 1,500 waste tires for less than 90 days. If excluded from permt•ccrr•vwe Pans B and D. If not excluded from;e*'it reew,e"+e^s cort'ete Parts B.C.and D. PART B–Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility �'�` r"'rte``' HAULING AND MANIFESTING REQUIREMENTS w��Vw& ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953 Contracts with Registered Waste Tire Haulers. ❑ ❑ ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. ❑ ® ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ ❑ 14 CCR§ 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. ❑ ❑ ❑ 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ ❑ ❑ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C–Inspection of Waste Tire Facility uirr3ment��3'F�.i�?` "` �'`�--'=�'`"��'f C� �C�" `C"� '14,CCR§:17352w:Site Secu'ritj►•Y _ - _Permits ❑ ❑ /❑ PRC§42824-Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑ (c)Access ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit .. ❑ ❑ ❑ PRC 42850(a) § complies with Terns of Permit •C: -�C C." ._ . §*.. �� -=-r-w-•.#•---•---- - ❑ ❑ El 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier [3 (2) Approved Vector Plan E] C] ❑ 14 CCR§ 18423 -Filing Application for Permit G' _[ '�=i 14`CCR§;17354 SfOragof.WasteTiiss Outdoois.; -�13 ❑(a)Storage Units ,ar -Recdrdkeeplrig Requfremegts;' ❑ (b)Fire Lanes ❑ ❑ �❑ 14 CCR§ 18432-Operations Plan ❑ (c)Fire District Requirements ❑ It CCR§11433-Emergency Response Plan ❑ (d)Drainage ❑ (e)Slope/Grade CCR§18447-Records Available ❑ (f)Siting(New Facilities) CCR 17351 FirerPreVeritiori Measures = '_. `. ❑ (g)Rim Removal § ❑ (h)Protection from Pyrolytic Oil Runoff (a)Communication Equipment _ ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 Indoor Storage fi ❑ (c)Water Supply Facility compliance with NFPA 231 D-1989 ❑ (d)Other Requirements