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`:: : ' Waste Tire Survey and Inspection Report city/county �:: Mailing Address �— Phone Number State of California CIWMB-54(10103) I PART A—General Information/Survey11I I Q1 Page ( of� `INSPEC71ONITE'1/1$tT, Type(Check one): Q- utine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility SWIS: _ = Inspected by::' Time In: Dat ,;, Regulatory Status: File No TPID: �ti i o J ❑Permitted [.�-Excluded❑ Exempt❑Unpermitted Code: Time Out: /totaltime: -Operational Status:: .� 4 Hauler ID: L M;l-yZ43 State'- } ®Active O Closed❑Inactive❑Planned Local: _ Business/Facility Name: Tire Count: Type: 4j Passenger❑Altered[]Truck❑OTR Address: Phone: Storage Type �— 7-7 rd 1 1� �Outdoor❑Indobr❑Container :t7,�- �. Owner: Ins ector Please Print): Business Rep: ` o Title: Faeili T check one) Role of Business:(Check authat;wM y. .��. ty ype:l ❑ Major WT (>S.o-:•: :•es) ' ❑Minor WTF(>soo ures) Waste Tire Location (<500 tires) ®Generator ❑ Hauler ❑End-use Business Type:(ctw-k an not appy) _, < KTire Dealer ❑ Retreader ❑Dismantler ❑ Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(check only tf Applicable): ❑ 14 CCR§ 1842J(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§ 18;20(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 permt,corrc,ce pars B and D. n not excluded from permit requirements complete Parts B,C.and D. PART B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility X, :CA I 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§ 18-459.1 (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 Rr+Pirmf&ReqNW� 'C"f aC j:C '14jCCR§17352;=Slte';Sectiritj/?� ` ❑ ❑ ❑ 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 53',{a'f'Ved ❑ ❑ ❑ 14 CCR§18420(a) –Applicable for Permit ❑ (1)Impermeable Barrier [1 (2) Approved Vector Plan E] E] CJ14 CCR§18423 –Filing Application for Permit ,`,14-CCP,§17354 Sge o toraf.Waste V49 Outdoors._ r .. •'Ya4+,e r4-: - - -t'y �f ?;.r4;>s ❑ (a)Storage Units y., _ ReciNdlteeping Requiremenfs ❑ ❑' -❑ 14 CCR§18432–Operations Plan ❑ (b)Fire Lanes ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433–Emergency Response Plan ❑ (d)Drainage 01 ❑ I Ill 14 CCR§18447–Records Available ❑ (e)Slope/Grade ❑ (f)Siting(New Facilities) -[ ❑; a[: 14 CCR§17351,'Fire Prevention Measures ❑ (g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ '14 CCR§17356 -lridoor Storage ❑ (c)Nater Supply ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989