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.. WastZ�I'ire Survey and Inspection R ort city/County / Mailing Address a�wr� State of California l Number CIWMB-54(10/03) PART A-General Information/Surveyo a� 2— Page I of _ `INSPEC710t�t;�SITE.1/1SIT; Type(Check one): FeRoutine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. Ins d b Time In Date f e ulato Status: FacilitySWIS.- pe Y Regulatory File No TPID: /` p L City ❑ Permitted [Excluded❑Exempt❑Unperrnitted £Y Code Time Out. to ime -Operational Status:,` Hauler ID: [ 10%7 ❑State I Active❑Closed❑Inactrve❑Planned Local: .? Business/Faci'ty Name: Tire Count:. - Type: E5Rassenger❑Altered❑Truck❑OTR Address: Ph o e: =Storage Type # r� Lt,7 '6 78sS <Q Outiner ja Y Owner: Ins ector(Please Print). Business Rep: \v> o ( I Title: Facility Type'(cne<ir one)- Role of Business:,(check all fttappyj r : ❑ Major WTF(,5.000::-es) ❑ Minor WTF(>500 byes) e>_l1/aste Tire Location (<soo tires) 9LGenerator ❑ Hauler ❑End-use Business Type:(check all ant appy) ...Tire Dealer ❑ Retreader ❑Dismantler Auto Repair ❑ Auto Body ❑Car Dealer ❑Collection! ' ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(check ony lf4plicabie)i . ❑ 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. W 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 permil.complete Pars a and D. tf not excluded from permit requirements complete Parts B.C.and D. PART B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility - - HAULING�ANDMANIFESTING REQUIREMENTSr" ?�L _' �ft + ❑ ❑ ❑ 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. ❑ ❑ ❑ 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. ❑ C1 El14 CCR§ 18,461 -Manifest System Requirements for Waste Tire End-Use Facilities. El [I C314 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART G-Inspection of Waste Tire Facility gip, `- '_Permits Requirements3" � ', 14;01CR§:17352`;Site Se M"?m Our El [I [IPRC§42824—Major Waste Tire Facility Permit El (a)Signs El (b)Site Attendant [I(c)Access [I El [IPRC§42834—Minor Waste Tire Facility Permit ❑ ❑ ❑ PRC§42850(a)—Complies with Terms of Permit [ 12+-, [ 14`CCFt§<ni7353'.(aec(o7?Coittrol' y •' " E] E] E] 14 CCR§18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier El (2) Approved Vector Plan ❑ E] E] 14 CCR§ 18423 —Filing Application for Permit ?•[ ,',[ "[t 14CCR§:17354";Storage of Wasfe Tlres Outdoors- "'r'N Recordl(eeping 12egG1rements z y 44 El (a)Storage Units E] E] C314 CCR§ 18432—Operations Plan El (b)Fire Lanes ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 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 [ '[ [ '14 CCR§17356 -Iridoor'Storage ° ❑(c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231D-1989