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f y ,. Waste iCity/Count re Survey and Inspection Report Mailing Address State of California Phone Number CIWMB-54(10/03) PART A-General Information/Survey )C, J�<< N;� �o�s..� �n�• �� Page of d" INSPECTION tSITE VISIl'g ,� Type(Check one) Routine ❑ Re-inspection ❑ Complaint ❑ Observation ❑CIWMB Referral ❑ CHP Referral ❑Other: Facility SWIS: Inspected by: Time In: Date: Regulatory St�aatvy+s� File No. TPID: ,� (9'County/City /� ;y5 _ 3 5 2 o ElI� Permitted 'Excluded❑ Exempt❑Unpermitted Hauler ID: Code: Time Out: Total Time: Opgrational Status: ❑ 3`�r [� Local: State f r;,�� Active EJ Closed E]Inactive EJ Planned Business/Facility Name:---, Tire Count: Ty e:)� ✓ QPassenger❑Altered ❑Truck❑OTR Address: /,� � � Phone: S�ttojjage Type: 4 c� uJc�[� r A Ve— Q'Outdoor❑Indoor❑Container Owner: C Inspe or(Please Print): Business Rep: me'o—lG l i��G�1C' ��r� P--%c_ Title: Facility Type:(check one) Role of Business:(Check all that apply) ❑ Major WTF(,5,000 tires) ❑ Minor WTF(,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 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 Facility V A G 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. ❑ ❑ ❑ 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 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 ❑ ❑ 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 [ ❑ ❑ 14 CCR§17351 -Fire Prevention Measures ❑ (f)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