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WastSurvey and Inspection Rep„ city/county Waste"i e L \ 1 1 �V_1ailfng Address • ��11n'� l� Phone Number State of California �r� - / p t CIWMB-54(10/03) Jv ` Vv �10��` PART A—General Information/Survey Page ` of I�Ll ��NSPECTION�SITEVIS Type(check one) iLRoutine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. FacilitySWIS:- �4 Inspected by.: Time In: wotTi .• ` Regulatory Status: File No.;; TPID: - p c$-eounty/City ," ❑Permitted$-Exduded❑ Exempt❑Unpennitted Hauler ID: Code TimeOut: e :Operational Stature:: Local: ❑'.State _ _ ¢ Active❑Closed❑Inactnie❑Planned Business/Facility Name: Tire Count: Type: \ EIPassenger❑Alt=_red❑Truck❑OTR A dress: Phone: Storage Type O 6 _ ❑Outdoor Glndoo"r❑Container - a Owner: Ins ectoror(Please Print): Business Rep: Title: Facility T (c one} Role of Business:(Check all that ppN) ❑Major WTF(,5.000 t res) ❑ Minor WTF(>500 tires) ll Waste Tire Location (<500 tires) S-Generator ❑ Hauler ❑ End-use Business Type:(check all that appy) f B-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): r< ❑ 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 perms,corrviete Pans 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 Facility Y: 14C* 'v ^"��-'r�_ _HAULINGAND MANIFESTING REQUIREMENTS ❑ ❑ ❑ 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. j ❑ ❑ ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ ❑I ❑ 14 CCR§ 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. 01 ❑ E]J 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. t ❑ ❑ ❑ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. i PART C—Inspection of Waste Tire Facility YRE 1D D ST. BAG QW_5A SIM '•�' `�;.�;£ _ -_P :, C-1 s[ :C -14aCCR§:17352:...Site".Secivitjr3' ,4 ❑ ❑ x❑ PRC§42824-Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit ❑ ❑ []I PRC§42850(a)-Complies with Terms of Permit .,17353' a 'VedCoiitro� C `C CH § ❑ ❑ ❑ 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 -Filing Application for Permit fir+ 14`CCR,§,17354=StoraW6f.Waite Tires Outdoes Recordtteeping RequTements.l" N`" El (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ 01 14 CCR§18432-Operations Plan ❑ (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`;=Fiie�P°revention Measures.';'`;;-'''' ❑ (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 231D-1989