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City/County Waste Tire Survey and Inspection Report Mailing Address State of California Phone Number CIWMB-54(10/03) PART A—General Information/Survey Page ( of Z % f a 6111 Type(Check one): ❑ Routine X Re-inspection ❑Complaint ❑Observation CIWMB Referral ❑CHP Referral ❑ Other: Facility SWIS: In ected by: Time In: Date: Regulatory Status: File No. TPID: ^ v(,��i — i�County/City 3=�I S 3 _5 LO ❑ Permitted ❑ Excluded❑ Exempt❑Unpermitted Hauler ID: Code: Time Out: Total Time: O)�erational Status: ❑State Local: Active F-1Closed E] Inactive F1 Planned 3 tJS �-�' ,. Business/Facility Name: Tire Count: Typ assenger❑Altered❑Truck❑OTR Address: Phone: Storage Type,// 9rQ j C�w✓o%oma ;' ':3'5z_-,-L,;, [�Outdoor Ef Indoor❑Container Owner: Inspector(please P Int): Business Rep: tAtu r� c C C Title: �fh-I -.c c• . tr Facility Type:(check one) Role of Business:(check all a at apply) ❑ Major WTF(>5,000 tires) ❑ Minor WTF(>500 tires) ❑Waste Tire Location (,Soo tires) [`Generator [Mauler ❑ End-use Business Type:(check all that apply) O'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 1d A ❑ ❑ ❑ 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. ❑ ❑ ❑ 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 S �NDARDS1 01 rX 10 ffASTE TIRE 5TZ3RAG TANDFtDS 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 ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑(b)Fire Lanes ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade 11 E: 14 CCR§17351 -Fire Prevention Measures EJ(g Siting(New Facilities) El(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