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' : City/County ., Waste'x re Survey and Inspection R"ML. Mallin Address 1 Serpa �a," hone Number State of California CIWMB-54(10/03) PART A—General Information/Survey Page of 1 N S P E CT{O NITE�V 1 S IT Type(Check one): fn-1Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. Facility' SWIS: Inspected by: Time In: Date Regulatory Status: File No., TPID: �{ L/�f O( +�CIty ❑ Permitted �Exduded❑Exempt❑Unpermitted Hauler ID: Code Time Out: tal ime: -_Operational Status:,` { _ ❑State Local: gchve❑Closed active❑Planned- Business/Facility Name: Tire Count:- Type: 0•Rassenger[]Altered❑Truck❑OTR Phone: -.-,Storage d...oT.oyrp❑e Address: Owner: �Insecr P�Z� nf): Business Rep: Indoof❑Coritatner 4' ` Title: Facili T check or+e) Role of Business:.(check all thai ipplyj tY ypef'1 ❑ Major WTF(>5.000:,•es) ❑ Minor WTF(>soo tires) [3-Waste Tire Location (<Soo Cres) ®.Generator ❑ Hauler ❑End-use Business Type:(chock an that appy) ,Tire Dealer ❑ Retreader ❑Dismantler Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑ Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe . . . . . . . .. .. I.... . 1. Excluded Business Types (Check only If Applicable): ❑ 14 CCR§ 18420(a) (3) - =cCilities storing less than 500 waste tires(Waste Tire Loca:on). ❑ 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 perm/.complete Pa's 8 arc D tf not excluded from pewit requirements complete Parts 8,C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 1f _HAULING D MANIFESTING REQUIREMENTS:t ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953 -Ccntracts with Registered Waste Tire Haulers. ❑ ❑ ❑ 14 CCR§ 18=5S 1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑ ❑ ❑ 14 CCR§ 18455 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 R '�� G1DaF2D ST. DARD ;'t -_Permits Requirertients" '++°«': '� '` 1r. 'Cf 'C+C=t =14,CC11§17352;=Site;Secu`rit}I ❑ ❑ ElPRC§42824—Major Waste Tire Facility Permit El (a)Signs C3(b)Site Attendant ❑(c)Access ❑ E] [I PRC§42834—Minor Waste Tire Facility Permit �t. (14-CCR:§17353' a=Nacio"�Cont{or' s ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [, [' C� - _ ( � .._ _ _ x -�- ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit '[?<[ 'Crn r.1*CCR§'17354'=Sforag of.WasIe;Tres outdoors '" ":�"s Recordkeeping Requferrierits:i" ` s , ❑ (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§ 18 447—Records Available ❑ (e)Slope/Grade �.,. ❑ (f)Siting(New Facilities) [' ❑ a❑_ 14 CCR§17351 =Fire(?reveiitiori Measures';' ':; ❑ (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water S.:ppiy El(d)Other Rez -irements Facility compliance with NFPA 231D-1989