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ENVIRONMENTAL HEALTH ' °- SAN JOAQUIN COUNTY Waste fire Surve Y and Ins ection Re o�`t 304 E WEBER AVE 3� Fi, P P •••• STOCKTON CA 95202-2708 State of California (209) 468-3420 CIWMB-54(10/03) PART A—General Information/Survey Page of° F e INSPECTION IS fTESIT vVIfy'� ,n Type(Check one) PfRoutine ❑ Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑CHP Referral ❑ Other: Facility SWIS: Inspected by: Time In: Date: Regulatory Status: File No. TPID: 2,L�j%- -- ❑County/City 6 2, ❑ Permitted ❑ Excluded 9 Exempt❑ Unpermitted Code: Time Out: T tatTime: Op erational Status: Hauler ID: ❑State Local: dive❑Closed❑Inactive❑Planned Business/Facility Name: (�, Tire Count: Type: l'Passenger❑Altered❑Truck❑ OTR Address" Phone: Storage Type: z 7 Jy cj Outdoor❑Indoor❑Container Owner: Insper(Please P nt): Business Rep: y� r,}`,r r1 _ - - S Title: Facility Type:(check one) Role of Business:(CheiA all that apply) ❑ Major WTF(,5,000 tires) ❑ Minor WTF(,500 Tres) ❑Waste Tire Location (<500 tires) 1�2 Generator ❑ Hauler ❑ End-use Business Type:(check all that apply) .IgTire Dealer ❑ Retreader ❑ Dismantler ❑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 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 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 �, V `A. MINISM C%% I 'LING AND MANIFESTING REQUIREMENT'S �9...,� r ❑ ❑ ❑ 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. ❑ ❑ 1 ❑ 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. ❑ ❑ ❑ 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. ❑ fW ❑ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C — Inspection of Waste Tire Facility V A cWASTE TIRE STORAGE STANDARDS V, " A 'C ' WASTE TIRE STORAGE STANDARDS Permits Requirements [ [ [ 14 CCR§17352-Site Security ❑ ❑ ❑ 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 [ [ [ 14 CCR§17353(a)-Vector Control ❑ ❑ ❑ 14 CCR§ 18420(a) —Applicable for Permit ❑ (1) Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 —Filing Application for Permit [ [ FE 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑ (a)Storage Units ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑ (b)Fire Lanes ❑ (c)Fire District Requirements ❑I ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade 14 CCR 17351 -Fire Prevention Measures ❑ (fl Siting(New Facilities) C ❑ [ § ❑ (g) Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b) Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply [I (d)Other Requirements Facility compliance with NFPA 231 D-1989