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City/County 5 Waste Tift6rvey and Inspection Repor tilaihngAddress Phone^Number State of California �'t'"'5�v1��yN CIWMB 54(1 Page I of 11 PARTA-Geneneral Inform at(on/Su rvey Type(Check one): Routine ❑Re-inspection E] Complaint [IObservation ❑CIWMB Referral ❑CHPReatrai ❑Other. Facility =SWIS: s In petted by�_' Time In: D tet Regulatory Status: County/City ❑Permitted Excluded❑Exempt❑Unpermitted File No TPID: Q Q Code- Hauler ID: r_{� '�(? Time Out: ota Time: Operationai Status s ` Im ❑'State Active❑Closed)]inac�ve❑Plann Local: �tre.Gount Type Business/Facility Na'me^:: '' f ($[Passenger❑Altered[]Truck[IOTR Phone: ' Storage TYPe:� � VA es a Outdoor p�tnd340 Cont? anew ase P'nt) Business Rep: sh 5��i wner:M SSA ` In Title: Q RfSine :(Check il►wt pvN? oleo, p Facility Type:(Check oeey f , Major WTF( s,000 tires) F1 Minor WTF t>50a tires) ❑Waste Tire Location (<500 tires) enerator ❑Hauler ❑End-use ❑ Busi ss TypeC Chack ap that aPpfyi;=,r,„ ,:c a' ire ❑Auto Repair [I Auto Body []Car Dealer ❑Collection Dealer ❑ El Retreader Crumb Rubber ❑Other Describe Lo ❑Trucking Fleet El Shredder ❑ »,x essTypes(cneckohty-xpiicaeie)`18420(a)(3)- Facilities storing less than 500waste tires(Waste Tire Location). 18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises. 18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. 18420(a)(7)8(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-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility V A':.,.0 1{AULING AND MANIFESa NoGR_QUIZ rt of Tires. t I ❑ ❑ Cl PRC§42951 (a)-Waste Tire Hauler Reg ❑ ❑ ❑ 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. ❑ ❑ 01 14 CCR§18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. ❑ ❑ ❑1 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ ❑ 01 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C-Inspection of Waste Tire Facility ❑ ❑ ❑ 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 M1 2 roved Vector Plan ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ ( ) APP ❑ ❑ ❑ 14 CCR§ 18427— e ling Application for Permit WET! § 7354 #OwaV.-ORWa 1!IIi i s Qi dim IMI- Reco�dkeepiriitrements' ' 'as"'�" ` ❑ (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§ 1843erations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§1843ergency Response Plan ❑ (d)Drainage ❑(e)Slope/Grade ❑ ❑ ❑ 14 CCR§184cords Available ❑ (f)Siting(New Facilities) " o x ❑ (g)j[k '14 CCR:§173e;P,everitiortMeasures . Rim Removal (a)CommuEquipment (h)Protection from Pyrolytic Oil Runoff (b)Fire Equt [ [: 14 CCR§17356•;-Indoor'Stora❑ (c)Water SFacility compliance with NFPA 231D-1989 ❑(d)Other Rents