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Wash lire Survey and Inspection Rt cart City/County :c ilin,Address c '�Jc �j C'a'"t� h a unber Sfa'ti of California / C!'/:'3-54(10/03) PART A—General Information/Survey ?age t of� - �iNSPECTIOPI�SITFsl�1SIT Type(�)eckone): ❑Routine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. b Time In: Date Regulatory Status: Facility _ SWIS: • Ins pe y:; File No.-. TPID: p ® /City ❑Permitted [3-Excluded❑Exempt❑Unpermitfed Time Out: I T tat Ime: :Operatronat Status:, vt - _ Hauler ID: Io1\civt ❑'State _ cbve❑Glowed❑Inactive❑Planned Local: - Business/Facility Name_ Tire Count:' Type: C2 -EWassenger[]Altered[]Truck❑OTR Address: A Phone: Storage Type is 70 ";❑ but indoor❑Container.f Owner. laspe for 2keasePrint): Business Rep: Title: I FafityType.`(cneciror,o) Role of Business(check auttuf�ppy) ❑Major WTF(>s.000i,res) ❑ Minor WTF(>500tires) [Waste Tire Location (-500 tires) 121-Generator ❑ Hauler ❑End-use Business Type:(cl»ck,u erne appy) moire Dealer ❑ Retreader ❑Dismantler ❑ Auto Repair ❑Auto Body ❑Car Dealer ❑Co!'ection F-1 Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(Check only if Applicable): '=CCR§ 18420(a)(3)- Facilities storing less than 500 waste tires (`.:`as:e Tire Location). I! 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. 1:CCR§ 18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. r..exaa.ec`.7 perms,complete Pans B and 0. if not excluded from permit requirements cornp'ete Pa.^.s B.C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _1f fi A MANIFESTING REQUIREMENTS ❑I ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. C I ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Haulers. ❑ ❑ ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from Clt,JMB. C ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. •I ❑ ❑ ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ []I Ell 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 ASTM. �1DI�RD _ .ST. - DAftD ' 'Permits Requiremerits'° j& :[-i M4 CCR§,17352 Site:Securitjr?'xm*a? i"' S; ❑ ❑ �❑ PRC§42824-Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Atxess ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit ❑ ❑ 01 PRC§42850(a)-Complies with Terms of Permit [T ''[: 111 ';14`:CCR§17353'.(a '�Vacf Coiitro r' ;{ > ❑ ❑ ❑1 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 -Filing Application for Permit [ yet ',14`CCR.,§;17354'=;Storagof,Waste Tres OutdooisWOW Recordi(eeplrig Requlrementsl_" ` ti El (a)Storage Units El (b)Fire Lanes C] -❑ 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) [= ❑: [t 14 CCR§17351`=Fire`Frevention Measures; El (g)Rim Removal E] (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff El (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989