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! YY w City/County Waste '1.. e Survey and Inspection Repo Mailing Address �•• Phone Number State of California i CIWMB-54(10/03) PART A—General Information/Survey Page of Type(check one): `Routine ❑Re-inspection ❑Complaint ❑Observation ❑ CIWMB Referral ❑ CHP Referral ❑ Other: in ed by ' Time In: Date:- �rul Regulatory Status: �/ Facility SWIS: ❑Permitted ❑ Excluded 21 Exempt❑Unpermitted File No. TPID/ _ County/City Code:. Time Out: ota Time: ' OActiicirtal.Status ve❑C osed S❑`Inactive❑ Planf Hauler ID: P _ ❑State _ ned Local Business!F cility Name: Tire Count: Type: ❑Passenger❑Altered❑Truck❑ OTR P Phoned ogr,®Storage Type:-' s 9 :r Addres j .5 <. Com/ '❑OutdIndoor ETb9ntziin6rk �r Owner Insp tor(Please Print): Business Rep: 5-1 \_r Rola of usir►ess:.(citeck auinatapvN? Facility Type:`tcheck one) ❑Major WTF(>5.000 tires) ❑Minor WTF(>500 bras) :iYWaste Tire Location (-Soo ores) f<Generator ❑ Hauler ❑ End-use B=ireDealer :(check all tha PvN) - - = Retreader ❑Dismantler ❑Auto Repair ❑ Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑Crumb Rubber ❑ Other:Describe : Excluded Business Types(6heckontilf4plfcabfe). t" ❑ 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 exuded from pernt requirements corroete Parts B.C.and D. PART B— Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility V p Cti ^� Ut'x. HAULING%1NDMANIFESTING REQUIREMENTS� rw ' ' `"E] El❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Haulers. ❑ ❑ I ❑1 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑I ❑ I ❑1 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. Cl ❑ ❑ 14 CCR§18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ ❑ ❑1 14 CCR§18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. ❑ ❑ ❑I 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ ❑1 01 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C•,Inspection of Waste Tire.Facility, - ST,O- IJ�1RD 9sy�s + tl 1 CCR' 17352-JS Sec r�, '�' �ermits;RegUirentents� '��,s:.�► - �`.. ["�t sC § ❑ ❑ ❑ PRC§42824—Major Waste Tire Facility Permit ❑ (a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit ;[' [ 4,kCCR r1Z353(a /�/e ,o o ' ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit c "" ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved vector Plan ❑ 11 DI 14 CCR§18423 —Filing Application for Permit [ ? '[kQ s 4`CCR§1:7354 "StofaWof^W ke;Tires,Outdoors;, r,. • ... ,.. [I (a)Storage Units ? Recordkeeprem ng Requients';. ❑ (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 El (e)Slope(Grade ❑ (f)Siting(New Facilities) [`- "❑1 yW 14 CCR,§17351=Fire preyentiof)Measures ❑ (g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [ [' .[•" '14 CCR§17356 -Indoor Storage ❑(c)Water Suppiy Facility compliance with NFPA 231 D-1989 0(d)Other Requirements