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City/County .., ' Waste ..re Survey and Inspection Repo t Mailing Address State of California �`�� J i'l�ch�,i^ ��''-�^+ ��' /�c .l�l. �P�+ {� Phone Number CIWMB-54(10/03) 7 PART A-General Information/Survey Page ) of�-- Type(Check one) Routine ❑ Re-inspection Q Complaint Q Observation Q CIWMB Referral ❑CHP Referral Q Other: Facility SWIS: Inspected by: Time In: Date: Regulatory Sta s: File No. TPID: r_1County/City L y 0t Q Permitted [2 Excluded ❑ Exempt Q Unpermitted Hauler ID: Code: Time Out: Total Ti e: 0 rational Status: Q State Local: LMActive❑Closed❑ Inactive E] Planned Business/Facility Name: Tire Count: TX-ypJe ElPassenger❑Altered❑Truck❑OTR Address: _ Phone: Stoybge Type: L - n �� t' �7a^-�c�c �- ct-2-,- (q�, [ `Outdoor Q Indoor Q Container Owner: Inspector(Please Print): Business Rep: �c 1^i . S Ctrs Title: Facility Type:(Check one) Role of Business:(Check all that apply) ❑ Major WTF(>5,000 tires) ❑ Minor WTF(>500 tires) Q Waste Tire Location (<e o tires) Generator ❑ Hauler Q End-use Business Type:(check all that apply) re Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair Q Auto Body ❑Car Dealer ❑Collection ❑Gas Station Q Trucking Fleet Q Shredder ❑ Crumb Rubber Q 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 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 and D. If not excluded from permit requirements complete Parts B,C,and D. PART B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facilit y f //. HAUL IN yR '7 Q ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ❑ Q ❑ 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ' ❑ Q Q 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. ❑ ❑ Q 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 V A C "WASTE TIRE STORAGE S FAyDARNO W, ,`,j „Y:. 'A C WASTE" ,. RAGE'STANDARQS 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 ❑ Q ❑ 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 ❑ Q ❑ 14 CCR§ 18423 -Filing Application for Permit [T T7[ 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 E 01 E: 14 CCR§17351 -Fire Prevention Measures Ll (f)Siting(New Facilities) ❑ (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989