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i Waste 1 re Survey and Inspection Reps city county ,.: Mailing Address Phone Number State of California CIWMB-54(10103) of PART A—General Information/Survey �� PageNMI �t h. ✓�V1 � NSPECTiON' -IT�"(`/ISIT Type(checkone): J�J-Roudne ❑Re4nspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. Facility ;' 'SWIS: n _Inspected by:,- Time In: Dat : tip; Regulatory Status Erle No S n +/Cay .,� 0. ❑Permitted c2-Excluded❑Exempt❑Unpennitted TPID: :Z 661 -O ( - Hauler ID: r ❑State Time Out: otal-rime: ,OperratIdnaVStatus r �} �. r` Acftve Closed❑,Inactive❑Planned. Local: - - �. Business/Facility Name: Tire Count.:: Type: —� Passenger❑Altered[-]Truck❑OTR Address: Phone: 4Storage Type:, y ,, 3�,�� ' �� " ��{,� �{��Ou`�doo,�D I�nc110or❑Container _~ Owner: Inspeetor(Please Print): Business Rep: ` GiS Title: ROIe'of B6ilr185s,(cireekaltthatapply) Facility Type (&.kone) ❑ Major WTF(ps.00e tires) ❑Minor WTF(>500 tires) ©Waste Tire Location (<500 tires) 9-Generator ❑Hauler ❑End-use Business Type:(check an that appryi) Tire Dealer EJ Retreader Dismantler El Repair El Auto Body ❑Car Dealer ]Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑Other Describe Excluded Business Types(cnectc'onyxaPPacanie): ❑ 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 permt,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 ` t ,+' HAUUNGAND MANIFESTING REQUIREMENTS"'� Ct 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 1121-CORK - j k' k ;PermitsRegtiirement 'Orth//". �'. °Cf -C ([ �14'CCR§.17352��SiteSec REI ❑ ❑ PRC§42824-Major Waste Tire Facility Permit (a)Signs ❑(b)Site Attendant ❑(c)Access ❑ [1PRC§42834-Minor Waste Tire Facility Permit ❑ ❑ ❑ PRC§42850(a)-Complies with Terms of Permit :14'CCR,§'1,7353'111"M Kiq_ ❑ ❑ ❑ 14 CCR§18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit :<[w* [ .t[ 14`CCR§"f1T354 ,S,ordgt#of Waste;Tires 0ufdoons;_. -Recordkeepin lbiquTements El (a)Storage Units ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§18432-Operations Plan El (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433-Emergency Response Plan El (d)Drainage C] E] C] El (f)Siting 14 CCR§18447-Records Available El (fSlope/Grade) (New Facilities) ; .: ❑ (g) [' '`❑ i[e 14 CCR§17351=Etre`*erition Measures _ Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [ [ [ 1 14 CCR§17356 '=In`door'Stoiage' : " . ❑(c)Water Supply Facility compliance with NFPA 231D-1989 ❑(d)Other Requirements