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ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY Waste ire Survey and Inspection Repoll < 304 E WEBER AVE 3R° FL W: STOCKTON CA 95202-2708 State of California (209) 468-3420 CIWMB-54(10/03) PART A-General Information/Survey Page of v INSPECTION t SITE VISITE Type(check one) [N Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑ Other: Facility SWIS: Inspected by: Time In: Date: Regulatory St tus: File No. TPID: v c• c -3 7I-u E-1 County/City r. �� ❑ Permitted Excluded E] Exempt F1Unpermitted Code: Hauler ID: ❑ State Time Out: Total Time: O erational Status: Local: Active❑Closed❑ Inactive❑ Planned Business/Facility Name: Tire Count: Type: i L �• I-,, ) /_ �—t , Passenger[]Altered ❑Truck❑ OTR Address: a Phone: Storage Type- -2 t z t tz c1--) 2 _5 3 ] ❑Outdoor 0indoor❑Container Owner: Inspector(Please Print): Business R p: Title: Ci c��'tn �i\'b v.�•c•' Facility Type:(Check one) Role of Business:(Check all that apply) ❑ Major WTF(-5.000 tires) ❑ Minor WTF(-500 tires) ❑Waste Tire Location (<500 tires) Generator ❑ Hauler ❑ End-use Business Type:(check all that apply) ❑ Tire Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair ❑Auto Body ' Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑ Shredder ❑ Crumb Rubber ❑Other: Describe Excluded Business Types(check only If Applicable): 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. ❑ 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,complete Parts 8 and D If not excluded from permit requirements complete Parts B.C.and D. PART B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility V A C HAULING AND MANIFESTING REQUIREMENTS ' ❑ ❑ ❑ 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. ❑ 1 ❑ ❑ 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. ❑ a ❑ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C - Inspection of Waste Tire Facility V A C WASTE TIRE STORAGE STANDARDS V A C WASTE TIRE STORAGE STANDARDS x Permits Requirements [ [ [ 14 CCR§17352-Site Security ❑ ❑ ❑ 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 Terms of Permit [ [ [ 14 CCR§17353(a)-Vector Control ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit ET—E—:7[: 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑(a)Storage Units ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑(b)Fire Lanes ❑(c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑(d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade ❑ (f)Siting(New Facilities) [ ❑ [ 14 CCR§17351 -Fire Prevention Measures ❑(g)Rim Removal ❑ (a)Communication Equipment ❑ (h) Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment 1--E-:J-[-:l [ 1 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply El (d)Other Requirements Facility compliance with NFPA 231 D-1989