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City/County Waste i Survey and Inspection Replo Mailing Address LH: Phone Number i State of California CIWMB-54(10/03) PART A—General Information/Survey S Page of 2. tJSPEG71i0 ! ,RITE'VIS Type(Check one): ®'Routine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑Other. Facility SWIS ` = insPectedy ry Time In: Dat ` Regulatory Status: ' o CI ` ❑Permitted Excluded Exempt❑Un File No TPID. fop .5 14{ "o xe ' `Cod Time Out: T tai Ime: wOperatlonal,Status •.•,,j nnitt Hauler ID: Su r c,,. Y= _.❑State Local: 17 - �Acbve❑Closed(]Inactive❑Planned _. Business/Facility Name: Tire Count: Type: i1 �a 029-assenger[]Altered❑Truck❑OTR Alw a D 'Storage'Type. Address: taneY ] ,>Od 5 , ,gi ,in -- VTYpe� e ns c Please Print): Business Rep. CIIt e• (Check one) Roh3ofBusiness:_(cnockauthaiappy> s ❑ Major WTF(>5,000 tires) z❑ Minor WTF(>500 tires) S-Waste Tire Location (<500 tires) Generator ❑ Hauler ❑End-use Business,Type:(Chock all that apply}J!I -Tire Dealer ElRetreader ❑Dismantler C]Auto Repair ElAuto Body ❑Car Dealer ❑Collection ❑ Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other Describe Excluded Business Types(check only HAppiicame): ❑ 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. 8- 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 °:1f` A C. •"x �_ - .•. Romig HAULING�AND MANIFESTING REQUIREMENTS ❑ ❑ ❑ 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 CIWMB. C] C] ❑ 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. ❑ ❑ ❑1 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 ST . BARDAll ' .x :Permits Requirement$ ' s . til "? ''. ;C"f`sC tC X14;CCR§`17352 'Ske",SecuritjVl6mA" � h ❑ ❑ ❑ 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 [.� 4, -46 h/e"CtControt ❑ ❑ ❑ 14 CCR§18420(a) -Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ 1:1 C] 14 CCR§18423 -Filing Application for Permit [ � 14`CCR.§17354; Storagt'of.Waste;Tirtas Outdotxs." i Recordiceeping Requements 1 " $ ❑(a)Storage Units �i ❑ (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 Y ❑(f)Siting(New Facilities) [` '❑ a❑5 14 CCR§17351`;=FirwPreyention Measures ❑(g)Rim Removal [I(a)Communication Equipment C1(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