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City/County Waste ire Survey and Inspection Repo t Mailing Address J c�e;cr i•_ L-C�ty. l y (�'-.0;rv.. +. ��tn �� `,("Phone Number State of California 7 • CIWMB-54(10/03) PART A-General Information/Survey CA Z2 Page I of 'Z INSPECTION t SITE VISIT .: Type(Check one): [Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other: Facility SWIS: Insp cted by: Time In: Dat Regulatory St�atyy'�� File No. TPID: 12-2-r+ 303-z-/ YCounty/City 7 j �. EJ Permitted ['Excluded❑ Exempt❑Unpermitted Hauler ID: Code:State Time Out: T tal time: O rational Status: Lc r�i►� ❑ Local: Active❑Closed❑ Inactive❑Planned Business/Facility Name: Tire Count: Ty LyJ Passenger❑Altered ❑Truck❑OTR �a 7 Address. 'Phone: Stoyage Type: Z,i IS'2 _ 7_2,2 Z Outdoor❑Indoor El Container Owner: Inspector(Please Print): Business Rep: Kr. CSN r C-7,, •- Title: Facility Type:(Check one) Role of Business:(Check all that apply) ❑ Major WTF(,5,000 tires) ❑ Minor WTF(,500 tires) Waste Tire Location (<500 tires) Generator ❑ Hauler ❑ End-use Business Type:(check all that apply) re 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): ❑ 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. Si_*'14 CCR§ 18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from permit,complete Parts 8 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 Facilit Vv� i4iJIING ANI}:MANIFESTING;REQUIREMENTS %i�,;.. „ . ❑ ❑ ❑ 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. ❑ ❑ ❑ 14C R§ 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 V A I C WASTE TIRE STORAGE STANDARDS; V A C y - WASTE TIRE ST' "�E STAND'' Permits Requirements [ 7E_T7 14 CCR§17352-Site Security ❑ ❑ ❑ 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 [ [ [ 14 CCR§17353(a)-Vector Control ❑ ❑ ❑ 14 CCR§ 18420(a) -Applicable for Permit ❑ (1) Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 -Filing Application for Permit [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑ (a)Storage Units ❑ ❑ ❑ 14 CCR§ 18432-Operations Plan ❑ (b)Fire Lanes ❑ (c) Fire District Requirements ❑I ❑ ❑ 14 CCR§ 18433-Emergency Response Plan ❑ (d)Drainage 01 ❑ ❑ 14 CCR§ 18447-Records Available ❑ (e)Slope/Grade E: El ❑ ( [ 14 CCR§17351 -Fire Prevention Measures El (g Siting(New Facilities) 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 231 D-1989