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Waste t'ire Survey and Inspection Report city/county <br /> Ltailino,Number Address <br /> State of California Phone <br /> CIWMB-54(10/03) <br /> PART A—General Information/Survey Page of�— <br /> INSPECTION I SITE VISIT <br /> Type(Check one) Routine ❑ Re-inspection ❑ Complaint ❑Observation ❑CIWMB Referral ❑CHP Referral ❑"Other:Facility SWIS: Inspected by: Time In: Date: Regulatory Status: <br /> File No. TPID: h ❑County/City L / - ❑Permitted 0 Excluded❑Exemp <br /> Code: <br /> Hauler ID: E]State Time Out: Total Time: O rational Status: <br /> Local: Active❑Closed❑Inactive❑Planned <br /> Business/Facility Name: Tire Count: Typ <br /> .- Sr [P <br /> Gr'+ie- assenger❑Altered❑Truck(]OTR <br /> r—r—�� 1�5 <br /> Address: t Phone: Stodge Typet,� <br /> /50, �=� 7�`I Z —Z Z U►outdoor L�Indoor E]Container <br /> Owner: In pectgf(Pleas Print): Business Rep: �r e 2-- <br /> Title: <br /> Title: <br /> Facility Type:(check one) Role of Business:(check all that.apply) <br /> ❑ Major WTF(>5.000 tires) ❑ Minor WTF(>500 tires) ❑Waste Tire Location (<500 tires) (Generator ❑ Hauler ❑End-use <br /> Business Type:(check all that apply) <br /> ire Dealer ❑ Retreader ❑ Dismantler ❑Auto Repair ❑Auto Body ❑Car Dealer ❑Collection <br /> ❑ Gas Station ❑Trucking Fleet ❑ Shredder ❑ Crumb Rubber ❑ Other: Describe <br /> Excluded Business Types(check only if applicable): <br /> ❑ 14 CCR§18420(a)(3)-Facilities storing less than 500 waste tires(Waste Tire Location). <br /> ❑ 14 CCR§18420(a) (4)-Tire retreading facility with no more than 3,000 waste tires on premises. <br /> ❑ 14 CCR§ 18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days. <br /> 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. <br /> If excluded from permit,complete Parts 8 and D. If not excluded from permit requirements complete Parts 8,C,and D. <br /> PART B— Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> V A C- = HAULINGAND MANIFESTING REQUIREMENTS _ . z <br /> ❑ ❑ ❑ PRC§42951 (a)-Waste Tire Hauler Registration and Transport of Tires. <br /> ❑ ❑ ❑ PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> ❑ 9 ❑ 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB. <br /> ❑ ❑ ❑ 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days. <br /> ❑ ❑ 14 CCR§ 18459.3 -Retention of Manifest Forms and Tire Trip Logs for 3 years. <br /> ❑ ❑ ❑ 14 CCR§ 18460.2 -Manifest System Requirements for Registered Waste Tire Haulers. <br /> ❑ ❑ ❑ 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities. <br /> ❑ g ❑ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. <br /> PART C—Inspection of Waste Tire Facility <br /> JrA .. <br /> WASTIIRE, ORAGE STANDARD, �"g, &1N%1STE`T1RE STORAGE'STAND <br /> Permits Requirements [ [ [ 14 CCR§17352-Site Security <br /> ❑ ❑ ❑ PRC§42824-Major Waste Tire Facility Permit <br /> ❑ (a)Signs ❑ (b)Site Attendant ❑(c)Access <br /> ❑ ❑ ❑ PRC§42834—Minor Waste Tire Facility Permit <br /> ❑I ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [ [ [ 14 CCR§17353(a)-Vector Control <br /> ❑ ❑ ❑ 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan <br /> ❑ ❑ ❑ 14 CCR§18423 —Filing Application for Permit [ [ [ 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Recordkeeping Requirements ❑(a)Storage Units <br /> ❑ ❑ ❑ 14 CCR§18432—Operations Plan ❑(b)Fire Lanes <br /> ❑(c)Fire District Requirements <br /> ❑ ❑ ❑ 14 CCR§18433—Emergency Response Plan ❑(d)Drainage <br /> ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade <br /> C: ❑ [ 14 CCR§17351 [:1 (f)Siting(New Facilities)-Fire Prevention Measures ❑ (g)Rim Removal <br /> ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff <br /> ❑ (b)Fire Equipment [ [ [ 14 CCR§17356 -Indoor Storage <br /> ❑ (c)Water Supply <br /> ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989 <br />