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ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY Waste Survey and Inspection Rep. 304 E WEBER AVE 3"D FL STOCKTON CA 95202-2708 State of California (209) 468-3420 CIWMB-54(10/03) rayc PART A—General Information/Survey .,s INSPECTION t,SITE VIS ° �,.fi v� x = Type(check one): joutine ❑ Re-inspection ❑ Complaint ❑ Observation% ❑_CJWMB Referral ❑ CHP Referral ❑Other. Inspected by: Time In: D te: Regulatory Status: Facility SWIS: ❑County/City 6 ❑ Permittedpxcluded❑Exempt❑UnpermittedV File No. TPID: Code: Time Out: tal ime: operational Status �� P Hauler ID: ❑State AcSve,(]"Closed❑Inactive❑Planned Local: Tire Count: Type:" Business/Facility Name: j�$assenger❑Altered[ Truck❑OTR O �� Phone: Storage"Type: Address: �I t, Outdoor❑Indoow❑Container \ ector(Please Print-)-:1 Business Rep: owner' ` 1t/A� Title: 2' Role of Business:(cheakallthatappty) ; 3s Facility Type:(check one) . . ❑ f.linor WTF(>50o tires) ❑Waste Tire Location (<500 ores) El Generator ❑ Hauler ❑ End-use F-1 Major WTF eckoo tires) Business Type:(chock all that appy) E]Tire Dealer [_1Retreader El Dismantler El Auto Repair' Auto Body []Car Dealer []Collection ❑ Gas Station ❑Trucking Fleet ❑ Shredder ❑ Crumb Rubber ❑ Other:Describe , Excluded Business Types(check only if Applicable): ❑ 14 CCR§ 18420(a)(3) Facilities storing less than 500 wade 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 permit,complete Parts B and D if not excluded from pe^ t requirements complete Parts B.C,and D. PARTn of Waste Tire Dealer, Generator, Hauler and End-Use Facility B— Inspectio ..�"r. V A C ,: �� -- HAULING-AND AND MANIFESTING REQUIREMENTS��.`a__ E] E] ❑ PRC§42951 (a)-`�taste 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. ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. ❑ p .❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. ❑ El El 14 CCR§ 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. ❑ p ❑ 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 p R �� [_ iR§1T 4CC ;352SIfe";Sec�iritj(�" ""7 its;Requliementilvili I:11 1:`•s� ❑* I0 ❑ ❑ ElPRC§42824—Major Waste Tire Facility Permit ❑(a)Signs ❑ (b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit §17353.(a�t"Vec{r Coritiol ' ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit ; 3 2 Approved Vector Plan El 1—] 14 CCR§ 18420(a) —App livable for Permit ❑ (1)Impermeable Baler ❑ ( ) PP El El E] 14 CCR§18423 —Filing Application for Permit [m. C+'t pC 14;CCR"§17354 " toragabf. aste Tres Outdoors- rr l ❑ (a)Storage Units �� ? 'Rec&dkee Ing`Requirements p ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR IS 18432—Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergencq Response Plan ❑ (d)Drainage ❑ (e)Slope/Grade ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (f)Siting(New Facilities) CCR 17351,:Fire ,Prevention Measures ❑ (g)Rim Removal [` 14 § ❑ (h)Protection from Pyrolytic Oil Runoff ❑(a)Communication Equipment ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 Indoor Storage ❑ (c)Water Suppiy Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements i