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J City/countyase . urvey and Inspection Repo Mailing Address C }+ Phone Number J �►v� �V r�n�i(DV' lten� State of California CIWMB-54(10/03) z0y Page 1 of—!!!Z PART A-General Information/Survey INSPECTION! StT_EGISIT Type(check one): if&•Ftoutine ElRe-inspectionE] Complaint ❑ Observation E] CIWMB Referral C]CHP Referral ❑Other- . Facility SWIS: Ins d by Time In: Date _' Regulatory Status: El Permitted El Excluded[I Exempt®Unpermitted File No TPID: 051 — ICity ,` _ Code Time Out: T tal ime. -Operational Status r z w «..�rrj�t* � 3 j-T t Hauler ID: ❑,State Active❑Closed❑Inactive❑Planned y �. - p Local: -Tire Count:-- Type: i Business/Facility Name: []Passenger[]Altered[]Truck❑OTR Ca T Storage Phone: g ,, Address: a0 6 _ `�Oiitdoor❑�iidoor Contatnf:r y: - ,- S� Ins ector(Please Print): Business Rep: wner: AO Title:C \O JJRole Business:.(chick all ihai spay} Facility T :(check One) El Major WTF(>s.000 n-es) ®.Minor WT (>soo ores) ❑ Waste Tire Location (c5oo ores) I&Generator Hauler ❑End use Business Type:(Check an that aapN} - Tire Dealer ❑ Retreader El Dismantler ❑ Crumb Rubber ❑ Other:Describe Auto Repair Auto Body []Car Dealer ❑Collection E] Gas Station [I Trucking Fleet E]Shredder E] Excluded Business Types(checkonylrApplicabie). -' ❑ 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)8(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. if excluded from permt,complete Parts B and D. M not excluded from pemit requirements complete Parts B.C.acd D. PART B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ r `:V', A CF 4 . c '*'r t �ULING AND MANIFESTING REQUIREMENTSe�'?'S-r�— �� r�- kJ ` ❑ ❑ ❑ 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 CIWh1B. ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. ❑ ❑ -[j 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ p ❑ 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 A 5 D� R Permits RequlrenientDY C 114,CCR 4.117351'5SfteT ts .c �_ ❑ ❑ ❑ PRC§42824—Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access ® ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit >; ;4CCR '17353,a ; e , Coro" , ❑ ❑ ❑ PRC§42850(,)—Complies with Terms of Permit `C. •� § b eB roved Vector Plan ❑ ❑ ❑ 14 CCR§18420(,) —Applicable for Permit ❑ (a)Impermeable Barrier ❑ (2) APP ❑ ❑ ❑ 14 CCR§18423 —Filing Application for Permit ?:[$;` [^ --'["'f "I4CCCR§17354"Storage of Waste Tires Outdoors a Storage Units Ric ordKeepingRequ"Yrement's_E' n„{ �' SVrf ❑(') 9 ❑{b)Fire Lanes ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ (e)Slope/Grade ❑ ❑ ❑ 14 CCR§18447—Records Available ❑(f)Siting(New Facilities) " ❑(g)Rim Removal '�_ i[=; 14 CCR§17351 Fire'Preventlon Measures„;;: ❑ (h)Protection from Pyrolytic Oil Runoff ❑(a)Communication Equipment ❑(b)Fire Equipment [ [ [ 14 CCR§17356 =Indoor Storage ❑ (c)Water Supply Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements