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i - City/County WasteTire Survey and Inspection Repor, Mailing Address Phone Number State of California CIWMB-54(10/03) Page!of� PART A—General Information/Survey Type(Check one): ❑ Routine,, Re-inspection []Complaint ❑Observation ❑ CIWMB Referral ❑CHP Referral ❑ Other: t Time In: at Regulatory Status: Facility SWIS:LL r Ins de y ❑Permitted ❑Excludedd l>ed ❑Unpermitted File No TPID: /O7/�D/ unty/City ] _ - Code Time Out: Total Time. Operational Status t, t Hauler ID:- ❑State ❑Active❑Closed❑inactive❑Planned Local: Tire Count: _I Type: Business)Facil' Name: ❑Passenger❑Altered❑Truck❑ OTR • .,,s:.y :Storage Address: Phone: s❑W6 AM AM _ Ins r,(please Print): I Business Rep' Owner: / Title: �dY. Facility Type:(C;heck oris)_ : Role of Business:,(chickautfuYaPpy) Waste Tire Location (c50o ores) Generator ❑Hauler nd-use ❑ Major WTF(>5,000 tires) ( ❑ Minor WTF( 50o ores) ❑ I r Business Type:(chock"au that,p9hfl 4 to Repair uto Body ❑Car Dealer ❑Collection> Dealer El Retreader C]Dismantler ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑Crumb Rubber ❑ Other:Describe Excluded Business Types(checionylf4plicable): r ❑ 14 CCR§ 18420(a)(3)-=r" �cilities storing less than 500 waste`tires(Waste Tire Lo-z'.cn). EJ14 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)&(e) Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from permit,complete Parts B arc o H not excluded from perm reGwrements complete Parts B.C.and D. PART B— Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility V A"_' C 7�r =ar :-:=x-•HAULING AND MANIFESTING REQUIRE H❑ ❑ 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. ❑ ❑ ❑ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C-Inspection of Waste Tire_Facility R ; E�.T.. . goy ❑ ❑ ❑ PRC§42824-Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access - ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit 4'CC - - 3 S. a ❑ ❑ ❑ PRC§42850(a)-Complies with Terms of Permit = �"' � roved Vector Plan ❑ ❑ ❑ 14 CCR§18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) APP k 3 4'CCR 17354=;Sto'ragf,VVaste;Ti"res 0utdoofs ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit CC''� § ❑(a)Storage Units "s? `Recoi'dkeepirig Requlreineiits: ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§18432-Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433-Emergency Response Plan ❑(d)Drainage [I(e)Slope/Grade ❑ ❑ C] 14 CCR§18447-Records Available77_ M b E](0 Siting(New Facilities) ,a -14'CCR 17351,=Fire Preyeniiori Measures';;;:_: ; ": ❑ (g)Rim Removal -C ❑. ❑< - § El (h)Protection from Pyrolytic Oil Runoff ❑ (a)Communication Equipment ❑ (b)Fire Equipment [ [ [' '14 CCR§17356 -Iridoor Storage r-%-- ❑ (c)Water Suppiy Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements