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• <br /> or <br /> City/County <br /> Waste Ti4purvey and Inspection Repor Mailing Address <br /> Phone Number <br /> State of California Sf►<f`I Cov^I V <br /> CIWMB-54(10/03) � A. �( ` ( _ ` Page of� <br /> ?ARTA-General Information/Survey u`r`n ���J�`�'�J <br /> Type(check one,, outine ❑ Re-inspection ❑ Complaint ❑Observation ❑CIWMB Referral El CHP Referral ❑Other. <br /> Facility _ Inspected by Time In: Dat c'' Regulatory Status: <br /> acility 'SWIS: lyy-r;unty/City ❑Permitted ❑Exclud xempt❑Unpermitted <br /> Fite No. TPID: ;Code <br /> Time Out: otal ime: Operational Status <br /> >tiauler ID. a Q State ❑Acfive❑CiDsed❑Inactive 0 Plan <br /> Local: <br /> ',frre Count Type: <br /> Busi ss/Facility Name: Passenger❑Altered❑Truck❑OTR <br /> ' Phone- -storage- <br /> Address: <br /> sto ge Address 7� Ql °0f❑lndooc❑Container ` -. <br /> rIns ctor(Please Print Business Rep: <br /> Ow er) r Title: <br /> �fb <br /> 'Rote of Business:.(chick all inacappM �f <br /> Facility Type:(Check one) <br /> F1 Major WTF(>s,000 ores) ❑ Minor WTF(>soo bras) /aste Tire Location (<500 fires) Generator ❑Hauler ❑End-use <br /> +^x7�, � „.i <s K"y ,:• < l..r �K t _ -,z' ..:`fis is*R <br /> Businass Type:(cnackaltthaiapplY .� <br /> Tire Dealer ❑Retreader ElDismantler ❑Auto Repair El Auto Body []Car Dealer []Collection <br /> ❑Gas Station ❑Trucking Fleet El Shredder E] Crumb Rubber ❑Other Describe r ti a <br /> bExclude�dBusiness Types(check only if ApD1(came) <br /> ❑ 14 CCR§ 18420(a) (3)- Facilities storing less than 500 waste tires(Waste Tire Location). <br /> ❑ 14 CCR§18420(a) (4)-Tire retreading facility with no more than 3,000 waste tires on premises. — <br /> ❑ 14 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. <br /> [❑ 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. <br /> If excluded from permit,complete Parts B and D. if not excluded from permit requirements complete Parts B,C,and D. <br /> PART B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> V A: .:C� "' HAULING AND'MANIFESTING'REQtiIREMENTS` <br /> ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. <br /> ❑ ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> ❑ ❑ ❑ 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. <br /> ❑ ❑ ❑ 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. <br /> ❑ ❑ ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. <br /> ❑ ❑ ❑ 14 CCR§18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. <br /> ❑ ❑ ❑ 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities. <br /> ❑ ❑ ❑ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. <br /> PART C-Inspection of Waste Tire Facility <br /> jPerrt%itsk u mei._ <br /> ❑ ❑ ❑ PRC§42824–Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access - <br /> ❑ ❑ ❑ PRC§42834–Minor Waste Tire Facility Permit _ <br /> �. <br /> T35 °ra�"?i con'Ir <br /> ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit - <br /> ❑ (1)impermeable Barrer ❑ (2) Approved Vector Plan <br /> ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit 4CCR§'17354' foragoflNaste:Tires oufdroo <br /> ❑ ❑ ❑ 14 CCR§ 18423 –Filing Application for Permit <br /> t : � ❑(a)Storage Units <br /> ;Pg <br /> ,!tic <br /> ❑(b)Fire Lanes <br /> [] ❑ ❑ 14 CCR§18432–Operations Plan ❑(c)Fire District Requirements <br /> (] ❑ ❑ 14 CCR§18433–Emergency Response Plan ❑(d)Drainage <br /> ❑(e)Slope/Grade <br /> ❑ ❑ ❑ 14 CCR§18447–Records Available ❑(f)Siting(New Facilities) <br /> ,--710 <br /> i '14 CCR,§1T35i=;`dire Prevention Measures �� ` ❑(g)Rim Removal <br /> ❑ (h)Protection from Pyrolytic Oil Runoff <br /> ❑(a)Communication Equipment �•¢; <br /> ❑(b)Fire Equipment `[ [; �[' -14 CCR§17356' <br />