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City/ County Waste i ire Survey and Inspection Repo t ^. --T j� .(_ Mailing Address State of California ,. �. J�'r��/�rvnMC: Phone Number "��t{– � ��E,%�.i-- �� CIWMB-54(10/03) �� fa 15-2_Z�> 2— . PART A—General Information/SurveyPage of ^ ry ,,Q.4, Type(Check one) U<outine ❑ Re-inspection ❑Complaint ❑ Observation ❑CIWMB Referral ❑CHP Referral ❑ Other: Facility SWIS: Inspected by: Time In: Dat Regulatory Staaty� File No. TPID: J.Z Z _�iLtis County/City ❑ Permitted [�Excluded[I Exempt E]Unpermitted Code: Hauler ID: State F� Time Out: Total ime: O rational Status: r w ❑ Local: Gd Active❑Closed❑ Inactive❑ Planned Business/Facility Name: Tire Count: TA� I . + -V/ m assenger❑Altered ❑Truck❑OTR 'moi Cit 2_0Address: �— Phone: St ge Type: •7,-7� L, C-- o,r,,y,, �—r 4-73_ —� 3f- �]Outdoor❑ Indoor❑Container Owner: Insp"tor(Please Pri t): �' 7 ) Business Rep: SE, V1 r"N rt-t-_ L- e. C; KL( r Title: Mi"S Facility Type:(check one) Role of Business:(Check all that apply) ❑ Major WTF(>5,000 tires) ❑ Minor WTF(>500 tires) EQAaste Tire Location (<500 tires) &KGenerator ❑ 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 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 Facilit HAULING AND''MANIFESTING REQUIREMENTS' „P ?� , tea. -. ANIAMMOM ❑ ❑ ❑ 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. ❑ ❑ El 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C — Inspection of Waste Tire Facility V A 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 ❑I ❑ I ❑ PRC§42850(a)–Complies with Terms of Permit [ [ [ 14 CCR§17353(a)-Vector Control ❑ ❑ I ❑ 14 CCR§ 18420(a) –Applicable for Permit ❑ (1) Impermeable Barrier ❑ (2) Approved Vector Plan ❑ ❑ ❑ 14 CCR§ 18423 –Filing Application for Permit [ I [ I [ 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 01 ❑ ❑ 14 CCR§ 18433–Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447–Records Available ❑ (e)Slope/Grade E El ❑ ( [ 14 CCR§17351 -Fire Prevention Measures ❑ (g Siting(New Facilities) g)Rim Removal ❑ (a)Communication Equipment ❑ (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