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wast"el e Survey and Ins ection Re OT[ City/ County N �y / P ` 1 � bVlaili Ad ess Sri(I/� V O III` `-��l .i�rotnwl w� k4ca 'C�Pir vp State of California /`� Ave-. �roI CIWMB-54(10/03) ` V PART A—General Information/Survey 5 Page 1 of 2 INSPEC710ITE�IISITwAll Type(check one): Routine ❑ Re-inspection ❑ Corr,:)laint ❑ Observation ❑ CIWh1B Referral ❑CHP Referral ❑Other. Facility' Ins cted b Time In: Date Regulatory Status: ty„ :: SWIS: - Pe. File,No TPID: l0 D �"�"'�Y/city ;Z:., d 11� El Permitted [ Excluded Exempt E]Unperrnitted Code. Time Out: T to Time ".Operational Status:; Hauler ID: 37 . ❑State _ - _ �r Active❑Closed❑Ina6fi e❑Planned : Local: Business/Facility Name: _ Tire Count..- Type: i 1�.A 153 Z� M,� ETPassenger❑Altered[]Truck❑OTR Address Phone: •Storage Type Outdoor❑Indoor®fontamer f :; _ Y O ner: Inspectorpease?-..ease Business Rep: N c7 O Title: F city VD `chsckone) Role of Business:(checkautfuiapply] ❑Major WTF(>s.00c:,res) ' ❑ Minor WTF(>soo tires) []-Waste Tire Location (<soo tires) ElGenerator ❑ Hauler ❑End-use BUsln@SS Type:(Check all thata PPNI Tire Dealer ❑ Retreader ❑Dismantler [!E�Auto Repair ❑Auto Body ❑Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(checkontyifApplicabie): ?'• ❑ 14 CCR§ 18420(a)(3)-Facilities storing less than 50:: .:aste tires (Waste Tire Location). ❑ 14 CCR§ 18420(a)(4)-Tire retreading facility witn no more than 3.000 waste tires on premises. ❑ 14 CCR§ 18420(a)(6)-Auto dismantler storing no mc-e 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,complete Pans B and D. If not excluded from permt rec%;--ents complete Parts 9,C.and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility AULING AND MANIFESTING REQUIREMENTS-7 ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953-Contracts with Registered `"Jas:e Tire Haulers. ❑ ❑ ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Fc..-ms 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. ❑ ❑I ❑1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ ❑I ❑1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility -_Permits Requirements. r%t � ?--rWV*f '[� ?14 CCR§173521=Site";Secu'ritj ❑ ❑ j❑ PRC§42824-Major Waste Tire Fatality Permit ❑ (a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit ❑I ❑ ❑ PRC§42850(a)-Complies with Terms of Permit [T [�= `[ 14`C_CR§17353'_{a'Vedo'�TCoirti ^� ❑ ❑ 1 ❑1 14 CCR§ 18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑1 14 CCR§18423 -Filing Application for Permit ::[�=EN[#E-j -14 CCR§.17354=Storag�of.Waste Tres Outdoois:_ Recordkeepirig Requ"frements.t": - 4?' El (a)Storage Units E] E] El14 CCR§ 18432-Operations Plan El (b)Fire Lanes ❑ (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`,=FkiIt a i6tiori Measures - ❑ (g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolybc Oil Runoff ❑(b)Fire Equipment EVE] [ 14 CCR§17356 Indoor Storage `^ K_ ❑(c)Water Supply ❑(d)Other Requirements Facility compliance with NFPA 231D-1989