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t Ire Surveyand Inspection Re City/county Was �,N: p tt1�� Mailing Address h L4 ne Number State of California CIWMB-54(10/03) ee"r- PART A—General Information/Survey 5Page l of 1NSFEC7lON •ITE.'GISI'I: Type(check one): Routine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility SWIS: - Inspe d by: Time In atb ;: Regulatory Status: File No TPID: p 11 tf /city ❑Permitted 13-Excluded❑ Exempt❑Unpennitted s ` Hauler ID: e - Time Out: ota Time Operational Status:, D:State __ ❑Closed❑Inactive III Planned �. Local s Business/Facility Name: Tire Count Type: S4aassenger❑Altered❑Truck❑OTR Ad re . Phone: Storage Type L rs , ❑Indoor❑C666iner Owner: Jlasp$,Gtgr(Pease Print): 'Business Rep: oTitle: .Faci ity Type.(Check one> F ?. :. aRole`of Business:_(check all that appN)'' ❑Major WTF(,5.00c-res) ❑Minor WTF(>50o ares) 4D Waste Tire Location (<500 tires) ®.Generator ❑Hauler ❑End-use Business.Type:(check an that aDPN} (94ire Dealer ❑ Retreader ❑Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑Crumb Rubber ❑Other:Describe Excluded Business Types(checkontjIfAppft.able)t ❑ 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 more than 1,500 waste tires for less than 90 days. g_14 CCR§ 18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from permit,cor Mete Parts B and D. If not excluded from pertnt re�uwrements complete Parts B.C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility HAULING AND MANIFESTING REQUIREMENTSrEs"�!` r: ❑ ❑ ❑ 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 Ipiin S D :k`{'£ r% -_Permits Requirements' °i:'c "`r M, RC1 sC"" C' E14CCR§;17352'=Sitei. ecuritY'V-T r[]o ❑ ❑ PRC§42824—Major Waste Tire Facility Permit [I(a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [? `[; `[ ,14 CCR17353'.ZVecfo Coititrolr ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ E] E] 14 CCR§18423 —Filing Application for Permit E,I A_29;14`..:CCR§'17354' Storage of.Waste;Tires;Outdoors._ :RecoFdkeeping`Re iu rremettts i" �` �'.,'s"4 ❑(a)Storage Units ❑ ❑ C114 CCR§ 18432—Operations Pian ❑(b)Fire Lanes ❑(c)Fire District Requirements E]I ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑(d)Drainage ❑ ❑ ❑ 14 CCR§ 18447 Records Available ❑(e)Slope/Grade 14 CCR 17351 'Fire'P,rev'en06n.Measures' ?` ❑ (f1 Siting(New Facilities) C ❑ aC § ❑(g)Rim Removal ❑ (a)Communication Equipment ❑(h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment '14CCR§17356":=lridoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989