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City/County Waste ire Surveyand Inspection RepIm o t x,498: ns r N Mailinc,Address State of California 14cJ44— ! Phone Number CIWMB-54(10/03) �' ✓L+ �'�t''�r'— A C. j 5I-rc fz: /� �I 5Z 0 y PART A-General Information/Survey Page of Z INSPECTION 1 SITE VISIT ' �- ` r�„� Type(Check one) Id Routine ❑ Re-inspection ❑Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other: Facility SWIS: Inspected by: Time In: Date: Regulatory Staat� File No. PID: [County/City ElPermitted ®"Excluded❑ Exempt E] Unpermitted t' Code: �Fiauler ID: El State Time Out: Total Time: Operational Status: Local: [Active❑Closed❑ Inactive❑Planned Business/Facility Name: Tire Count: Typ : Cr,'jl '-I--3v ❑ assenger❑Altered ❑Truck❑OTR Address: >e Phone: Storage Type- L� a, �— L r ��CI. `7 L� ❑Outdoor Lo Indoor El Container Owner:. {��ti Inspector(Please Print): Business Rep: r-re� L7�,L k4:.5 Title: Facility Type:(check one) Role of Business:(Check all that apply) ❑ Major WTF(,5 000 tires) ❑ Minor WTF(,500 tires) 511waste Tire Location (<500 tires) [Generator ❑ Hauler ❑ End-use Business Type:(check all that apply) ire 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. 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 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 V A C15, "HAUL TNG AND MANIFESTING ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953-Contracts with ReJistered 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 V A C WASTE TIRE STORAGE STANDARDS', ,.; ._� V A C WASTE TIRE STORAGE STANDARDS Permits Requirements [ [ [ 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 ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [ [ [ 14 CCR§17353(a)-Vector Control [I El F114 CCR§ 18420(a) —Applicable for Permit El (1) Impermeable Barrier ❑ (2) Approved Vector Plan El E] E] 14 CCR§ 18423 —Filing Application for Permit [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements El (a)Storage Units El El El 14 CCR§ 18432—Operations Plan ❑ (b)Fire Lanes ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade ❑ [ 14 CCR§17351 -Fire Prevention Measures ❑ (f)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