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City/County Waste ire Survey and L Inspection Repot Mailing Address ':::: �jC1 y� �C9 Ct Y.11-� �.-Cjl.a h i' �4'�1/ �/� �C�•� /� �-. r State of California 3t3 '-f" G �'�`'� la✓e Phone Number CIWMB-54(10/03) �— PART A-General Information/Survey ' Page of INSPECTION/SITZ ' y- �, ; Type(Check one) outine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other: Facility SWIS: Inspe�c�d by: Time In: Dale: Regulatory Statu . File No. TPID: 3' '7 _;� ( County/City1 t:> ElPermitted Wxcluded EDExempt ElUnpermitted Hauler ID: Code: Time Out: Total Time: Optional Status: Local: ❑State LilActive El Closed❑ Inactive❑ Planned Business/Facility Name: Tire Count: Type: �� ►�5 -Y ElKssenger❑Altered❑Truck❑OTR Address: __7> Phone: Storage Type: Ave 4?4LL_ L7Cj 13 ❑Outdoor El Indoor❑Container Owner: Inspector(Please Print): Business Rep: C—,, � l- , 5 Title: Facility Type:(Check one) Role of Business:(Check all that a ply) ❑ Major WTF(,5.000 tires) ❑ Minor WTF(,500 tires) [D&aste 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 B and D. If not excluded from permit requirements complete Parts B.C.and D. PART B- Insp ection of Waste Tire Dealer, Generator, Hauler and End-Use Facilit V " ll 4 A C HAULING AND MANIFESTING REQUIREMENTS�, � �� e ❑ ❑ ❑ 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 V A C WASTE TIRE STORAGE STANDARDS V I A I t`, WASTE TIRE STORAGE STANDARDS 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 C C C 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 01 ❑ ❑ 14 CCR§ 18433-Emergency Response Plan ❑ (d)Drainage ❑I ❑ ❑ 14 CCR§ 18447-Records Available ❑ (e)Slope/Grade [ I ❑ [ 14 CCR§17351 -Fire Prevention Measures ❑ (f)Siting(New Facilities) ❑ (g) Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [ Eff T[ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989