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aF� City/County Wastt iL ire Survey and Inspection Repo f Mailing Address State of California # V�V Phone Number infer fir\ Y CIWMB-54(10/03) h PART A-General Information/Survey Page of z— Ftfia INSPECTION/SITS VISIT Type(Check one): Routine ❑ Re-inspection ❑Complaint ❑ Observation ❑ CM/MB Ref-7-al ❑CHP Referral E]Other: Facility SWIS: Inspected by: Time In: DateV. Regulatory Statu : File No. TPID: y��,� ❑County/City L} 7 F1Penr;tted xcluded❑Exempt ElUnpermitted Code: Hauler ID: ❑State Time Out: Total Time: O rational Status: Local: Active❑Closed❑Inactive❑Planned Business/Facility Name: Tire Count: Typ -I.- too assaenger❑Altered❑Truck❑OTR Address: Phone: Sttojage Type: I+La, f\-) �r �� I-)-62,_0_) p Outioor Q Indoor❑Container Owner: Inspector(Please Print): Business Rep: /ook".—Ic-( 51tkti16 r� Title: Facility Type:(check one) Role of Business:(Check all that apply) ❑ Major WTF(>5,000 tires; ❑ Minor WTF(>5oo t res) ❑Waste Tire Location (<500 tires) e-erator ❑ Hauler ❑ End-use Busin ss 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 z_ys. JZ 14 CCR§ 18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 c=ys. If excluded from permit,complete Pars B and D if not exc.�ded from,ermit 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. ❑ ❑ ❑ 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. ❑ ❑ ❑ 1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C-Inspection of Waste Tire Facility mo ASE �rATRISTORAGESTANDARD$' I " Permits Requirements C: C: 14 CCR§17352-Site Security E] EJ [JPRC§42824—Major Waste Tire Facility Permit El (a)Signs E](b)Site Attendant El (c)Access C3 El El PRC§42834—Minor Waste Tire Facility Permit [ ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [ C C 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 [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑(a)Storage Unas ❑ ❑ ❑ 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 [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989