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Wasteire Surveyand Inspection R"pt City/County P _ Mailing Address 1�*I� Phone Number State of California � ) CIWMB-54(10/03) - , W 1 PART A—General Information/Survey c�� Page—1 of S m!NSPECTIC)NStTE:\!1SIT Type(check one): R-Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility ; SWIS: Inspected by Time In: Date ? Regulatory Status: File No TPID: t�j 6 7\� � /City 2 ❑ Permitted [3Excluded❑Exempt❑Unpermitted Code: Time Out: tal ime: -Operational Status , - Hauler ID: sc .❑State { _ Local: [ ,fictive❑Closed❑In'acUve❑Planned Business/Facility Name: Tire Count:- Type: 2j - • eassengeF[-]Altered❑Truck❑OTR Ad ress: Phone: Storage_Type Cr Outdoor❑Ind66rTa-C6ntatner f Owner: Ing Spector Please Print): Business Rep: Title: Fac tty Typer(chera one) ss:(Check all that apPy) R61e of Busine ❑ Major WTF(>5.000:,-es) ❑ Minor WTF(>500 tires) I�Waste Tire Location (<500 tires) -aGenerator ❑ Hauler ❑ End-use Business Type:(cnack an trnt appy) ,Tire Dealer ❑ Retreader ❑Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer []Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(che<k onty If 4ilcable): _ >; ❑ 14 CCR§ 18420(a)(3) ~aci:i5es 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)8(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from permt,corrp!eie Pans B and D N not exduded from permit requirements complete Parts B,C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility •+•-. :r-*-_r-.t._.,. y -rt �Y r � %�"_ .'.•_"r: �. ..r!'~*` ..�.: ..A. :C"• Grn`•�-rs�-�^:--=_HAULINGANDMANIFESTING 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. ❑ ❑L❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ ❑ []1 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§ 18,462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility RZ=O.)�G. IDXRD. � ` ' 7CC £fxt }1jCCR§1T3b2 SlteSeity "-Prmis ReurnWtW1, "; �` Wu -. ❑ ❑ ❑I 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 [� `[ °C� I4`CCR§�17353',(a�''�VectCai>tiof ❑ ❑ ❑ 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier El (2) Approved Vector Plan ❑ E] ❑ 14 CCR§18423 -Filing Application for Permit [�' '[ '4Crr 14 CCR§`17354=Sforagof.Wasfe;Tres Qutdoora.4 `"` 'y"r` 'r= Reco`diceeping Requirements."` r 4 f` El (a)Storage Units El ElEl❑ 14 CCR§18432-Operations Plan C1 (b) Fre Lanes (c)Fire District Requirements ❑ ❑ []1 14 CCR§ 18433-Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑1 14 CCR§ 18447-Records Available ❑ (e)Slope/Grade 14 CCR 17351 Fire-Fre` ntlon Measures ❑ (�Siting(New Facilities) [`: '❑ �['. § ❑ (g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment - ` El (c)Water Su �� C C 'C 14 CCR§17356 =lridoor'Storage pp) ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989