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. Waste i ire Survey and Inspection_ Re City/County 0: „� L ailing Address U\,,,k4 ber State of California �� CIWMB-54(10/03) �jC7 _ �/✓�� PART A–General Information/Survey Page�of�— ItJSPEC710N;�,S1,T;E'VISfT Type(Check one): JE]-Routine ❑Re-inspection ❑ Complaint ❑ Observation ❑ CIWMB Referral ❑ CHP Referral ❑Other. Ins cted b Time In: Dat wf,, Regulatory Status: Facility; SWIS: _ pe y; File No.;= f ��/CItY �.' � ❑ Permitted ❑ Excluded[-Exempt❑Unpennitfed TPID: Code Hauler ID: ❑State Time Out: tai tme: :Operational Status, , { > _=: —- _ ❑Acfive❑Closed❑tn'active❑Planned` Logi: _ _ Bus ssl Facility Nam 'Tire Counb: . T 133 Passenger[-]Altered❑Truck❑OTR C,G,9, - k6 Ad ess: n Phone: Storage ! { V Q.�. 2 tdoor❑Indoof❑Contatner Owner:: 1 InSpBrIOs4Ptease Print): Business Rep: .0 Title: Facil- ype:(check one) Role usiness:.(checkantha£appb) ❑ Major WTF(>5.000:i-res) ❑ Minor WTF(>5co tires) ❑Waste Tire Location (<500 tires) ❑ Generator ❑ Hauler ❑ End-use Business Type:(check all that apply) "' s.n. ❑Tire Dealer ❑ Retreader ❑Dismantler ❑Auto Repair ❑Auto Body ©Car Dealer ❑Collection ❑Gas Station ❑Trucking Fleet ❑Shredder ❑ Crumb Rubber ❑ Other: Describe Excluded Business Types(check ontylf 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)8(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from permt.complete Pans B and D. If not exciuceo from peril requirements complete Parts B.C,and D. PART B –Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility +' -.r 7•#-c '}ir+•hf - _ irk. t .,' ... �• 3 i� .1f` A :C+• tarc��.R---�=-.-.�•.-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. r❑ ❑ E] 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. ❑ ❑ ❑ 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. PART C–Inspection of Waste Tire Facility TM -_PermitsRequin3ments'` x","< " ?": 1 : 14;CCR§17352❑ 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§ 18420(a) —Applicable for Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan ❑ 14 CCR§18423 —Filing Application for Permit <.[w' ,'[ 4� 14`CCR..§:17354 ;Storage of,Waste;Tires Outdoors,;-Rech Keeping Requrements .. � ❑ (a)Storage Units ❑ 14 CCR§18432—Operations Plan ❑ (b)Fire Lanes ❑ (c)Fire District Requirements ❑ 14 CCR§18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑1 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade ❑ (f)Siting(New Facilities) [`• ❑ i❑k 14 CCR§17351 Fire Prevention Measures ❑(g)Rim Removal ❑(a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑(b)Fire Equipment [. "[ [ 14 CCR§17356 Indoor Storage ? ZA ❑(c)Water Supply 0(d)Other Requirements Facility compliance with NFPA 231D-1989