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i City/ County `Vaste 1 It.c Survey and Inspection RepoMailing Address ��• Phone Number State of California CIWMB-54(10/03) PART A—General Information/Survey Page ---of "INSPECTION�fSI'T1=�(IS�_ -Type(Check one): Routine E]Re-inspection ❑Complaint ElObservation ❑CIWMB Referral E]CHP Referral E] Other: Facility '' SWIS: tns ed by::--:— Time In: !Dt '" Regulatory Status: �File No TPID/ ate/�/ �-'�untylCity ❑ Permitted ❑ Exc udect'[J txempt❑Unpermfitted Code Time Out: l Time: O octal Status r �>.' -Hauler ID ❑Stare ❑Closed(]Inactive❑Plann'ed ._.. Local: r:•�a Business/Facility Name: Tire Count:" Type: ❑Passenger[]Altered[]Truck❑ OTR Phone: -Sto a Type:, Address S C ndoor. Container^ a Ownr: Inspector ease Print): Busines,Rep: Title: FaciliyType:'(Checkone) . Rote'of Business."(ci,eck au thai aPpNl ❑ Major WTF ps,000:res) < ❑Minor WTF(>seo byes) aste Tire Location (<seo Gres) 'Generator & mauler nd use Busine Type:(check all thatappb) Erlire Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑Crumb Rubber ❑ Other: Describe i Excluded Business Types(check onlilf 4plicable): ❑ 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 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 permit,conowe Parts B a-d D. If not excluded from perml requirements complete Parts B,C,and 0. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility }ar-*= , .0 +t V A`` C" ' -. s: HAULING AND MANIFESTING REQUIREMENTSAR ftw ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. E] El El PRC§42953-Contracts with Registered Waste Tire Haulers. E] [:] ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. El El ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. ❑ E3 ❑ 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. El ❑ ❑ 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 w. . 4 '"� �,[+�.a❑❑ � �14CCR§`Z35?.�SlfeSacu[ r' r :.1'e� .Re9uirement� s � = ❑ ❑ ❑ 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 4;kCCR 7353 a e o Co tco ❑ ❑ ❑ 14 CCR§18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan x 4'CCR; 17354 Storage,0!.,lfaste;Tires Outdoo ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit [.. " -.. § � cp (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§18432-Operations Plan ❑ (c)Fire District Requirements ❑ ❑ [1 14 CCR§18433-Emergency Response Plan ❑ (d)Drainage ❑ ❑ E] 14 (e)Slope/Grade 14 CCR§18447-Records Available ❑ (f)Siting(New Facilities) 14-CCR.§17351,=FIre Preyentio6 Measures ❑ (g)Rim Removal El (a)Communication Equipment El (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [' [` .["' '14 CCR§17356 -Indoor Storage ❑ (c)Water Supply Facility compliance with NFPA 231 D-1989 ❑ (d)Other Requirements