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' _ r City/County Waste ire Survey and Inspection Re rt IlailingAddress � e C �/ ' �✓Lv� h N ber State of California J o•�/syr-> �((�� /y � ` CIWMB-54(10/03) , �e�o�� PARTA—General Information/Survey Page�of�-- 11 "IN5Pmal ig EC710N�IT�- � Type(check one): aRoutine ❑ Re-inspection ❑Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. FacilitySWIS: Inspected by: Time In: Dat P` Regulatory Status: File No TPID: fifty ❑Permitted ❑ Excluded D-Exempt❑Unpermitted Hauler ID: — Code Time Out: otal ime :Operational Status:, ❑.State Y- - ❑"Active❑Closed[ Inactive❑Planned Local: _ " Business/Facility Name: Tire County- Type,- 7 ❑Passenger❑Altered❑Truck❑OTR Address: Phone: Storage Type � � It^, O Y;❑'Ou#dooF❑Indoor❑Container �, � ~.�'�' l`r r Owner: ,nspector_mease Print)t Business Rep: Title: Facili ,Typeck:(cheone) - Role of sines:(Check an that ippN) ys T ❑ Major WTF(>s.000:,res) ❑ Minor WTF(>5ooures) ❑Waste Tire Location (<500 tires) ❑ Generator ❑Hauler ❑End-use Business Type:(check all that apply) ❑Tire Dealer ❑ Retreader ❑Dismantler ❑Auto Repair ❑Auto Body @Gar Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(check ony xtipplicable): ° `> ❑ 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 permt,corripiete Pans B and 0. If not excluded from perrrit requirements co(-4'e.e Parts B.C,and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility p C "ir `,�•_.I C '{� .'sem *r t HAULING AND MANIFESTING REQUIREMENTS aY i $ F=i1 Yr '•.T u � ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. ❑ ❑ [_1 PRC§42953-Contracts with Registered Waste Tire Haulers. ❑ E] ❑ 14 CCR§ 18459.1 (a) (b) (c)-Tire Program ID Number from CIWMB. p ❑ ❑ 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 Regj;6tered Waste Tire Haulers. ❑ ❑1 ❑ 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ ❑I Ell 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C—Inspection of Waste Tire Facility -_PenTtits Requirementeyzll e'r."iw",g�. . "`ir' `: -C` C` -C '14,CCR§17352;=Site:SeCu'ritjl?' r' x❑ PRC§42824—Major Waste Tire Facility Permit El (a)Signs [:](b)Site Attendant ❑(c)Access E]7: C] PRC§42834—Minor Waste Tire Facility Permit ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit _.[ `[� `[ 14'.CCR§17353'(aj'Vecfo"i,.Coirt_, ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan '^ §. 9 t ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit [ [ fC"=1 14,CCR, 17354`=;Stora a,of.Waste;Ti�es Outdoors; RecoidKeeping Re uTrementsi'� ❑ (a)Storage Units q ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§18432—Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§18447—Records Available ❑ (e)Slope/Grade C1 (f)Siting(New Facilities) Er `[3" �[ '14 CCR§17351',=Fire-Prevention Measures,'; ❑ (g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [ [ [ `14 CCR§17356 IridoorStotage = ❑ (c)Water Supply ` ❑(d)Other Requirements I Facility compliance with NFPA 231D-1989