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Was e 'tire Survey and Inspection R",, city/county y I 1 Mailing Address State of California , CIWMB-54(10/03) w c� PARTA—General Information/Survey Page of L W5F?ECTIONSfTEiVIS1T_ OF A110 IN Type(check one): ED-Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. — Facili '� Inspected by: Time In: Date <` Regulatory Status: ty SWIS: - un City ❑Permitted [-Excluded❑ Exempt❑Unpermitted File No._ TPID: O Code Hauler ID: ❑.State Time Out. T tat rime: ;Operational Local: - I�;Active❑'Closed❑Inactive El ha Business/Facility Name: Tire Count::' Type: BPassenger❑Altered❑Truck❑OTR Address: �e•v\� Phone: Storage Type x ps� t l .. .. --� �3 1�Outdoor[�Indoof❑Container Owner: nq: Business Rep: Title: Faeili T cneuc one} Role of Business:_(check all chaff appiyj ry ype (• ❑ Major WTF(,5.000 tires) ❑ Minor WT (>500 ures) [-)-Waste ice Location (<500 tires) Generator ❑ Hauler ❑End-use Business Type:(chock all that appy) Dire Dealer ❑ Retreader ❑Dismantler ❑P.-:o Repair ❑Auto Body ❑Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑ C%mb Rubber ❑ Other:Describe Excluded Business Types(check only ffApplicabie): 5- ❑ 14 CCR§ 18420(a) (3) - Facilities storing less than 500 waste: s (,.:'ante Tire Location). ❑ 14 CCR§18420(a)(4)-Tire retreading facility with no more t,-B-, 3,000 waste tires on premises. ❑ 14 CCR§ 18420(a)(6)-Auto dismantler storing no more thar ,500 waste tires for less than 90 days. ®__14 CCR_§ 18420(a)(7)8(e)-Tire dealer storing no more than .500 waste tires for less than 90 days. If excluded from permit,complete Parts B and D- If not excluded from permit requirements cor.re Pais B,C,and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility HAULINGAND MANIFESTING REQ UIREM ENTSr � �`iNi ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Ha.aers. ❑ ❑ ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Numbe,'om CIWMB. ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms ono T.re Trip Logs within 90 days. ❑ ❑ ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and T..e Trip Logs for 3 years. ❑ ❑ ❑ 14 CCR§ 18460.2 -Manifest System Requirements fo-Registered Waste Tire Haulers. ❑ ❑ ❑1 14 CCR§ 18461 -Manifest System Requirements for\' aste Tire End-Use Facilities. ❑ ❑ E]J 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility IDM_ SI DARD ^% -_Permits Requirements' sit:; "4� :'u =C• FC{ s.0 '14,CCR§;17352=Ske";S4aff jr?' ❑ ❑ �❑ PRC§42824-Major Waste Tire Facility Permit ❑ (a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit ❑ ❑ ❑ PRC§42850(a)-Complies with Terms of Permit [ [ `Ew 14;CCR§17393'.(a'Vecfo�.CorttioT �ya' ❑ ❑ ❑ 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit `'[= C � 14`CCR,§17354„SEorago,.q.. ;s4e;Tjrt s"Outdoors RecordKeeping RequTements Y" �' -':'s ' ❑ (a)Storage Units El (b)Fire Lanes E] El El14 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=Fire`Prevention Measures',';% ❑ (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [T[ 14 CCR§17356 Indoor Storage t ' ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989