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City/ County Waste i ire Survey and Inspection Report Mailinc, Address Phone Number - State of California 7�^ J CIWMB-54(10/03) V PART A— General Information/Survey Page_of INSPECTION f SITE VISIT Type(Check one) Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑CIWMB Referral ❑CHP Referral ❑ Other: Facility SWIS: Inspected by: Time In: Date: Regulatory Stat)6s: File No. TPID: 1 j C, 7 1 f- C;f ❑County/City i LfI,, �,: ❑Permitted ['Excluded ❑ Exempt❑ Unpermitted Code: Time Out: To6l Ti e: Operational Status: Hauler ID: ❑ State Local: Active ElClosed❑ Inactive❑ Planned Business/Facility Name: Tire Count: Typ assenger❑Altered ❑Truck E] OTR rt_ Address: Phone: Stop6ge Type: c Outdoor❑Indoor❑Container Owner: Inspe r(Please Print): / Business Rep: Title: Facility Type:(Check one) Role/of Business:(Check all that aWy) ❑ Major WTF(,5 000 tires) ❑ Minor WTF(,500 fires) ❑Waste Tire Location <v)0 tires) Generator ❑ Hauler ❑ End-use Business Type:(Check all that apply) Tire Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑ Gas Station ❑ Trucking Fleet ❑ Shredder ❑ Crumb Rubber ❑Other: Describe Excluded Business Types(check only if Applicable): ❑ 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;fres 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 and D If not excluded from permit regwrements complete Pa^.s B C and D. PART B — Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility V A C HAULING AND MANIFESTING REQUIREMENTS ❑ ❑ 01 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. ❑ ❑ ❑ 1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C — Inspection of Waste Tire Facility Y :.;`°l C° n,WASTE TIRE STORAGE STANDARDS, ... Y= 'A`' 'C ASTE 7IRig IkAGE'STAND"D 12DS. Permits Requirements [ [ [ 14 CCR§17352-Site Security ❑ ❑ ❑ 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 [ [ [ 14 CCR§17353(a)-Vector Control ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑(a)Storage Units ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑(b)Fire Lanes ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade 14 CCR 17351 -Fire Prevention Measures ❑(g Siting(New Facilities) C ❑ [ § ❑(g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply 71 ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989