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Waste Ire Survey and Inspection Re t City/county..: �' p Mailing Address hone Number State of California CIWMB-54(10/03) li qtr� • PART A—General Information/Survey i vZ Page I of 1)" .INSPECT}ON� ITEEVI Type(Check one): 6-Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility S i Inspected by:- Time In: Date Regulatory Status: Ftle No TPID: \0 6 t7lJL /CIty El Permitted aExcluded El Exempt E]Unpermitted Code' Time Out: T al im :Operational Status , .; µ{ ,, -� auler ID: _ ❑State.-- dive❑Closed❑Inactive❑Planned Local: s Business)Facility Name: Tire Cotint:-,. Type: B ❑ []Truck7/ Passenger Altered Truck[I OTR C7 �; . Phone: rStorageType :-e Address r L �� ( Outdoor❑Indoor❑Contarner ' Ow er: // Please Print): Business Rep: .fy ciS�� o Title: Facility T rtche<ir ? Role of Business:(crack all that appb) y3. r ❑ Major WTF(>5.000;.res) ❑Minor WTF(>soo ores) S-Waste Tire Location (4500 tires) fia Generator ❑ Hauler ❑ End-use Business Type:(check an that appM) [Tire Dealer ❑Retreader ❑Dismantler ❑Auto Repair ❑Auto Body []Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑Other: Describe Excluded Business Types(checkonytf4piicabte): ❑ 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 perm!.corrpiete Pans B and D. 0 not excluded from remv recc,rernents complete Parts B.C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility VI- p14404-� -_.•.t.HAULING AND - - �r { •r. . 'a;ry" :JY .}�% t - �!' - MANIFESTING REQUIREMENTS ..•�`'�,f:- - u-��->~�' .. +r:_:�.._�"'-_ts�f.Y.�'�.,�. ❑ ❑ ❑ 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 - �C.�'S5IDECItD 8T. DARD 7E: [] rs -Permits Requirement "i L '�' u�= 'j': °C*4Cx tC� =14,CCR§1735V1-SIteS❑ PRC§42824—Major Waste Tire Facility Permit El(a)Signs [:1 (b)Site Attendant ❑(c)Access PRC§42834—Minor Waste Tire Facility Permit ❑ ❑ 01 PRC§42850(a)complies with Terms of PermitCCR§'17353,(al5Vecf Coirtior _ .+ - ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§18423 —Filing Application for Permit >[w' 'C� a.xC 14`CCRl_'17354„Storage of.Waste;Tires Outdoois ! -Recordkeeping'RequTementt;.V".. El (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 �� _. ❑ (f)Siting(New Facilities) [:`: ❑ [: 14 CCR§17351=FIre'P.(even_0on Measures,`';< ❑ (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [ [ [ '14 CCR§17356'-IridoorStorage , ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989