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1 • :: Wa"tele Survey' and Inspection Report city county1 Mailing Address ho,Uelu��ber State of California CIWMB-54(10/03) PART A—General Information/Survey 2p Page Z L INSPECTfON�ITE�/ISIT� Type(check,,,,;- aRoutine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility SW1S: _ Inspected by Time In: Dat ' Regulatory Status: File No. TPID:\o `�� ` �� ®&a'/City >� ❑Permitted ❑Excluded El Exempt❑Unpermitted Hauer ID: x Code Time Out: ota ime. :OperationaLStatur., .� Low . [].State- _ '.®;4c6ve E Closed❑Inactive❑Planned.. Business/Facility Namg_ Tire Count: Type: ❑Passenger❑Altered❑Truck❑OTR 5 Phone: Storage Type- Address:, spa f� d79 '.�Outdoor❑Indoor❑Contatner `; ,;. 4 Owner: Ins eetor(Please Print): Business Rep: Title: Facility Type'(cre�sk one) Role of Business:(check all that appy) . ❑ Major WT t>s. •-::-es) ❑ Minor WTF(>Sootires) [Waste Tire Location (<500 tires) El Generator ❑ Hauler ❑End-use Business Type: (cr«ik an that apply) (�Tire Dealer ❑ Retreader ❑Dismantler ❑Auto Repair ❑Auto Body []Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(Check ontyIfApplicahle): ❑ 14 CCR 5 :-:!=2J (a)(3)-Facilities storing less than 500 v:as'e:,,,as (Waste Tire Location). ❑ 14 CCR§ 13=20(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises. ❑ 14 CCR b 18=23(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. ® 14 CCR§ 18=20(a)(7)8(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from perp_r1-o e!e Parts B and D. H not excluded from permit requirements--c,c!e!e Parts B,C.and 0. PART B— Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility :;:HAULING•AND MANIFESTING REQUIREMENTS t: �s�;,��{ fyr 'r.;,�;,�" == it': +� ► = �+e yl["� ❑ ❑ ❑ PRC §42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ ❑ FRC § 42953-Contracts with Registered Waste Tire Haulers. ❑ ❑ ❑ :s CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. ❑ ❑ ❑ :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. ❑ ❑ ❑ 1 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility C '14�CCR ;1732; SiteSecrity?r ' Permrt� " C =- ` [ t ❑ ❑ ~❑ PRC§42824—Major Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit ❑ ❑ C]l PRC§42850(a)—Complies with Terms of Permit [? [D- `[H 114 C_CR§z17353.(iJ Vedo"7.Coi 6rr1 ❑ ❑ E] J 14 CCR§ 18420(4) —Applicable for Permit El (1)Impermeable Barrier El (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§18423 —Filing Application for Permit ,14'CCR.§:17354=;St_orage of.Waste;Tires Outdo&s; coidkeePing RequTemenE§tv ❑ (a)Storage Units Re E] E]_ C] 14 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 [1 (f)Siting(New Facilities) Er' '0%i j[i 14CCR§17351?FI4PreventlonMe`asures' " -`... El (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage - ,' '",; ❑ (c) 'later Supply J (d)Other Requirements Facility compliance with NFPA 231 D-1989