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i City/County Waste Tiry purvey and Inspection Reo�\I_ Lfailin;Address j k Phone Number State of California 3 CIWMB-54(10/03) S�2 C�J�� S53"76�t$ Pae of PART A—General Information/Survey S�c.� � cA 5 g 1NSFEC7lONSiTE�•'GISIT� Iil 2 Type(check one) Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. Facility IHa 1S: -Ins ed b Time In: Date �> Regulatory Status: Peet :. Y A. File No : ®County/City Z.• y ❑ Permitted 9 Excluded❑Exempt❑Unpennitted ID: /008 CodeTime Out: tal ime: OperationafyStatus, _; Nuler lD: =:_B State A ❑Closed❑Inactive❑Planned cal: Business/Facility Name: Tire Count.:- Type: ❑Passenger❑Altered❑Truck[3 OTR `%Oh W Stora e T _ ... —••,�. Phone: Address: t SO�� tdoor O lndoor�Contdtner , 1 ` _ s.-� Owner: Inco for tF+—P-'.;1• Business Rep. � .' � Title: Role of Business::(cn:ckanmaiappN) Facility Type''(eheck o-) ❑ Major WTF(>5.Y.,-res> <❑ Minor WTF(>500 t,res) ❑ Waste Tire Location (<500 tires) ®Generator Q Hauler ❑End-use Business Type:(check all that appfyl _ .- , ; f ®-Tire Dealer (�Retreader [I Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Cclection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other.Describe Excluded Business Types(check only if4pil'-we): ❑ 14 CCR§ 13420(a)(3)- Facilities storing less than 500 v,2ste tires(Waste Tire Location). 14 CCR§ 18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises. ❑ 14 CCR§ 18,120(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. ® 14 CCR§ 18420(a)(7)&(e)-Tire dealer storing no more Lean 1,500 waste tires for less than 90 days. If excluded from permit,cc-c'e'e Pans B and D. If not excluded from permt reGure r+ -s con-alete Parts B,C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityL iz f .x=err --,•;HAULING'AND MANIFESTING REQUIREMENTS: x►,.- MC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. C§42953-Contracts with Registered Waste The Haulers. CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. CCR§18460.2 Manifest System Requirements for Registered Waste Tire Haulers. CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility AST7 �GD - ST` G _ DARD ` :* permits Requirements „ �}�..�"<f'g '" �"•� t.[ tC" `[ "14,CCR§.17352.' Site.Secu`ritjl?'�.+' s -� ❑ ❑ x❑ PRC§42824—Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit ,` :, T14,CCR: 17353'.a 4=gVe' Cot>trof `=a, ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit C.: .[ ,[ § - ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit [W' �[?(-°C"t 14`C.CR§:17354 ;Storageof:WasteTres Outdoors !'w ":*1 Recordkeep}ng RequTerrients y:• ❑(a)Storage Units ❑(b)Fire Lanes ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑(c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433—Emergency Response Plan ❑ (d)Drainage ❑ (e)Slope/Grade 14 CCR 18447—Records Available ❑ ❑ ❑ § ❑ (f)Siting(New Facilities) ❑ (g) [: ❑ �[: 14 CCR§17351=FireWere intlon Measures,'; ,:.-:_" Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage i ❑(c)Water Supply Facility compliance with NFPA 231D-193? ❑ (d)Other Requirements