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City/ County ;,..;.: Waste i ire Survey and Inspection Report Mailing Address State of Californ a " �- t co`..r 4.7 ��vt'rvr•�--Fa Phone Number CIWMB-54(10 03) PART A—General Information/Survey Page L of�-- o INSPECT,ION`FSITE.VISIT - a tiF• ,", �r .> . Type(check o-_ ❑ Routine Re-inspection ❑Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other: Facility SWIS: Inspected by: Time In: Dat Regulatory Stats: File No. TPID: lo3 oo/_01 [ICounty/City F 7, ❑ Permitted Excluded❑Exempt❑ Unpermitted Code: Time Out: Total Time: Operational Status: Hauler ID: ❑State Lccal: CilActive❑Closed El Inactive El Planned Business/Facility Name: Tire Count: T�yyp� L}Passenger❑Altered❑Truck❑ OTR Address: Phone: Storage Type. "11 W)7, _ ❑Outdoor Indoor❑Container Owner: Inspector(Please nnt): Business Rep: 7 Title: Facility Type:(check one) Role of Business:(check all that apply) ❑ Major WTF >5 ac_•es, ❑ Minor WTF(>500 tires) ❑Waste Tire Location (<5cc KYGenerator ❑ Hauler ❑ End-use Business Type:(Check all that apply) Tire Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair ❑Aur:o Body ❑Car Dealer ❑Collection ❑ Gas Static- ❑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 Locancn). ❑ 14 CCR§ 18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises. ❑ 14 CCR 6 13420 ia)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. CV-14 CCR o :8420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. if excluded from per—'�-z=es acs B and D If not excluded from permit requirements complete Parts B,C,and C. PART B— Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility V A I C HAULING AND MANIFESTING REQUIREMENTS ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Haulers. ❑ ❑ ❑ 4 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑ ❑ ❑ -4 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. ❑ ❑ ❑ '4 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 OW . WMenRESTORAGESTANDARD` % :i iHtr> iii TORKGl SAI DAIiQ�� 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 ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit [ E-17-C 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 ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e) Slope/Grade [ ❑ [ 14 CCR§17351 -Fire Prevention Measures El (g Siting(New Facilities) ❑ (g) Rim Removal ❑ (a)Communication Equipment ❑ (h) Protection from Pyrolytic Oil Runoff (b)F.re Equipment E: E: [ 14 CCR§17356 -Indoor Storage (c)V�la'er Supply (d)O:her Requirements Facifrty compliance with NFPA 231 D-1989