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City/County Waste ire Survey and Inspection Reps Mailing Address Phone Number State of California CIWMB-54(10/03) Page_7L of PART A-General Information/Survey NMI i 1NSPEGO�� S Type(Check ane): ❑ Routine e-inspection ❑ Complaint ❑Observation ❑CIWMB Referral ❑CHP Referral ❑Other. Facility SWIS:: =Inspected by Time In: Dat Regulatory Status: File No 3,666 nty/City I D ❑ ermitted d ed❑Exempt p ud Exe t Unpermitted TPID: Code_ t. Time Out: T I ime :Operational Status Hauler ID:- ❑State.:.- _ cbve❑Closed❑lnactrve❑Planned. Local: Tire Count: Type: Business)Facility Name: = ssenger❑Altered[]Truck[3OTR r Phone: _ -Storage Type Address door- Indoor❑-Containers I r(Plea Pri t): Business Rep: A& N O er: Title: y Roleof,Business::(tii, lranthacappty) U FacilityTy (cfieckonel : -x El Major WTF(>s,00e tires) ❑ Minor WTF(>500 tires) ❑Waste Tire Location (c5oo fires) Generator ❑Hauler ❑ End use Business Type:(check all that'apptyl. .:.. ' Car Dealer ❑Collection ,�Cire Dealer C]Retreader EIDismantler EJAuto Repair ❑Auto Body ❑ 777777 *Exclude�d:[Bds as Station ❑ ❑ 21 Trucking Fleet Shredder El Crumb Rubber ❑Other Describe ,;: 4 t= iness Types(check onlyx 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 Gres on premises. F❑ 14 CCR:§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. n 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 Band D. if not excluded from permit requirements complete Parts B.C.and D. PART B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Faciltt ,y ,v. .. Y; A; :C 0404* a',:HAULING AND MANIFESTING REQUIREMENTS . ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. El El 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 ME ecmits' u�re a slf ❑ ❑ ❑ 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 roved Vector Plan ❑ ❑ ❑ 14 CCR§18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier (2) App ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit [+ ( 4;`CCRA _7 %% (Q ge oflNaste Tires Ot>}doo j � ' `Recoiclkeepin'g'Requ rem" ntsR ' {'` ;. ❑(a)Storage Units ❑(b)Fire Lanes ❑ ❑ ❑ 14 CCR§18432—Operations Pian ❑(c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433—Emergency Response Plan ❑(d)Drainage ❑(e)Slope/Grade ❑ ❑ ❑ 14 CCR§18447—Records Available ❑(f)Siting(New Facilities) (g)Rim Removal *[r; �_•'14 CCR.§17351 P�everi#ion Measures r E](g) (h)Protection from Pyrolytic Oil Runoff ❑(a)Communication Equipment El(b)Fire Equipment [ `[ [" '14 CCR§17356�,=Iridobe'Storage a s R ❑(c)Water Supply Facility compliance with NFPA 231D-1989 ❑(d)Other Requirements