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i city county ste " lurve and Inspection Re o %rWaMailing Address Phone\umber I State of California CIWMB-54(10/03) PART A-General Information/Survey76 9 Pageof� s , i INSPEC1101!1, tTEaVISIT111151 i:'111 Type(Check one): lg-Routine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CI'YVMB Referral ❑ CHP Referral ❑Other. Facility SWIS: Inspected by: ETimeIn: Date` Regulatory StatFile No.` County/City 2- U? ❑ Permitted Exclud ❑Exempt❑Unpermitted TPID: �."Hauler ID: Code• Out: T tat ime: Operational Status •. :_ State _ g Active❑Cfosed❑Inactive❑Planned 'r J Local: Business/Facili Name: Tire Count: Type: u �\5 ❑Passenger❑Altered❑Truck❑ OTR Address: �y Phone: Stora ype:; sr - 1u a �' 6� -�I l ❑ utdoor❑Indoof❑Container S — ce Prin : Owner: noast) Business Rep: \- S Title: Facilityype:'(check one} �D Role of 6 ness:(Check all that ippl l - ❑ Major WTF(>s.00c:fres) ❑ Minor WTF(>soo tires) ❑ Waste Tire Location (<soo tires) ❑ Generator ❑ Hauler ❑ End-use Business Type:(check all mat apply) ❑Tire Dealer ❑ Retreader F Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shred er ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(Check only IfAppllcame): ❑ 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!.cornpie!e Parts B and D. If not excluded from permt requirements complete Parts B.C,and O. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility Y `A C" . :'HAULINGANDMANIFESTING REQUIREMENTS-t�r3`�� s •: r`= --� ❑ ❑ ❑ 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 VM k' Permits Requirementsrlr 4' at` .' "' s ` '[ -C" [°7t '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 7 t ..1'4�CCR "17353 a�=1%do?�Corrtrot - ❑ ❑ ❑ PRC§42850(a)-Complies with Terms of Permit [ �`[ C., -. § t � - ❑ ❑ ❑ 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan TAM ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit [° [ s[�=14'CCR§17354 _Storage`of:Waste Til Outdoors Recoidkeeping RegUlrements ."` ;x;"' ❑ (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ Y❑ 14 CCR§ 18432-Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433-Emergency Response Plan El (d)Drainage El El 14 CCR§ 18447-Records Available ❑ (e)Slope ❑ (f)Siting(Grade (New Facilities) ❑ [ 14 CCR§17351=FIre'Preventlon Measures ❑ (g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment `` r [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements 1