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ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY j Waste ire Survey and Inspection Rept,. c 304 E WEBER AVE 3' , STOCKTON CA 95202-2708 State of California (209) 468-3420 CIWMB-54(10/03) PART A—General Information/Survey Page of INSPECTION 1 SITE VISIT x' 1 Type(Check one) Routine ❑ Re-inspection [I Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other: Facility SWIS: Inspected by: Time In: Dat Regulatory Status: File No. Dc' E]County/City Z�y o<r- Elmitted PerExcluded E] Exempt C1Unpermitted TPI : Z' �i3 1- r Code: Hauler ID: ❑State Time Out: T tal ime: Operational Status: Local: ❑Active• ]Closec ,inactive❑ Planned Business/Facility Name: Tire Count: Type: d C C ❑Passenger[]Altered []Truck❑ OTR Address: Phone: Storage Type: / C__ cY ❑Outdoor❑Indoor❑Container Owner: Ins pe lease Pant): / Business Rep: Title: Facility Type:(Check one) Role of Business:(check all that apply) ❑ Major WTF(,5.000 tires) ❑ Minor WTF 1,500 tires) ❑Waste Tire Location (<500 tires) ❑ Generator ❑ Hauler ❑ End-use Business Type:(check all 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 only it 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 e=c>_ced from permit requirements complete Parts 6.C,and D. PART B— Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility V A C 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. ❑ ❑ I ❑ 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. ❑ ❑ ❑ 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C— Inspection of Waste Tire Facility V A I C WASTE 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 [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑ (a)Storage Units ❑ E-] ❑ 14 CCR§ 18432—Operations Plan [I (b)Fire Lanes ❑ (c)Fire District Requirements ❑1 ❑ ❑ 1 14 CCR§ 18433—Emergency Response Plan ❑ (d) Drainage ❑ ❑ ❑ 1 14 CCR§ 18447—Records Available ❑ (e) Slope/Grade ❑ (f)Siting(New Facilities) [ ❑ [ 14 CCR§17351 -Fire Prevention Measures ❑ (g) Rim Removal ❑ (a)Communication Equipment ❑ (h) Protection from Pyrolytic Oil Runoff ❑ (b)Fire Equipment [T[ [71 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989 / bL 1�' rf.5 Gi Lam- c.c ��_ )h C >IS