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City/ County - `Vaste •l,r<e Survey and Inspection Repo Mailing Address Phone Number State of California CIWMB-54(10/03) / PART A—General Information/Survey i? Page"-/Of > ' -INS Type(check one): a Routine ❑Re-inspection ❑Complaint ❑Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other: Facility, SWIS " Time In: Date: Regulatory Status: Inspected by: File No. TPID. �, ) -��i unty/City �✓� ,1 ❑Permitted ❑Excluded{Exempt[IUnpermitted `Code Time Out: Total Time: ;Operational Status Hauler ID ❑State ;❑Active❑Glosed❑Inactive❑Planned }„ Local: Business/Facility Name: _ Tire Coant: Type: ,Q ❑Passenger❑Altered❑Truck OTR //�>— ✓%t'�_5> -Stora Addres Pho Indoor:❑Container Owner: Inspector(Please Print): Business Rep Facili T checkone) - Role of Busirtess:.(thick all thatappNj -'. >._ �s:A ❑ Major WTF(>5,000 tires) ❑Minor WTF(>500 tires) Waste Tire Location (<500 tires) ❑ Generator ❑ Hauler ❑End use Busine Type:(check all that xPPN) Tire Dealer ❑ Retreader ❑Dismantler ❑VAuto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑ Shredder ❑Crumb Rubber ❑ Other:Describe Excluded Business Types(checkonylfAppllcable): ❑ 14 CCR§ 1Z420(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. It excluded from permit.complete Parts B and D. If not excluded from penrlt requirements complete Parts B.C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility FEE:]] HAULINGAND MANIFESTING REQUIREMENTS❑ 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 G Dwig iiiiii ..'��{„r�;'1y1j'� �.b„BrrTtits';Rega�rement�,�: r,�+�,..�'��*'� ��' `"-C� �❑� x`14,'',CCR'§',77352-;�,5[feSeCu •Aly r`T .s PNfiP F -r• ❑ ❑ ❑ PRC§42824—Major Waste Tire Facility Permit ❑ (a)Signs ❑(b)Site Attendant ❑(c)Access - ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit [Ell El PRC§42850(a)—Complies with Terms of Permit '` 4 CCR. 17353,(a=h/e„or;Controt ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan CCR 17354`Stoiago of,Waste,7ires-0utcloors ❑ ❑ ❑ 14 CCR§ 16423 —Filing Application for Permit [ - " '°$ Recordkeeping Regtl)rements ';.” '°` ❑ (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§18447—Records Available ❑ (e)Slope/Grade ❑ (f)Siting(New Facilities) E, ❑; ;[ 14 CCR_§17351,=Fire Prevention Measures," ❑ (g)Rim Removal El(a)Communication Equipment El (h)Protection from Pyroly is Oil Runoff ❑(b)Fire Equipment [ [ [ '14 CCR§17356 -Indoor Storage %'Sr ❑ (c)Water Supply Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements