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■ ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY Waste* Survey and Inspection Re . . 304 E WEBER AVE 3� FL q1 �,I STOCKTON CA 95202-2708 State of California y (209) 468-3420 CIWMB-54(10/03) PART A—General Information/Survey �.. IIJSPEC�{OPt',�,SITEVIS,�,. - Type(Check one): ❑ Routine ❑Re-inspection ❑ Complaint ❑ Observation WIWMB Referral ❑CHP Referral ❑Other. Inspected by Time In: Dater Regulatory Status: Facility" SWIS: ❑ Permitted ❑Excluded❑Exempt❑Unpermitted File No." ❑County/City TPID: Code: Z Hauler ID: Time Out: Total Time: "_O rational Status ❑State : dive❑'Closed❑inacHVe_❑Planned.� s.. Local: 'tire Count:" Type:. Business/Facility Name: Q , Vpassenger -]AlteredTruck El OTR Q Phone: Storage Type: ,' ` ��Address: ` L_ ❑Outdoor❑tndoo�❑Container . Business Rep: d �( Owner ' IpeAe for tPl� ease Print t ' ` Title: &A.)OLA_ Rote of Business:.(checkall that iIPPN1 s .4 Facility Type.(clock ons) C]Major WT (>s.coo tires) < ❑ Minor WTF(>5oo tires) ❑Waste Tire Location (<500 fires) El Generator Hauler ❑End-use Business Type:(chock all that aPpb) Car Dealer ollection ElTire Dealer ❑ Retreader ElDismantler ❑Auto Repair LJ Auto Body ❑ Crumb Rubber ❑ Other. Describe El Gas Station [I Trucking Fleet [I Shredder ❑ fs� Excluded Business Types(check onlyrca;Pplicable): � - ❑ 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)3(e)-Tire dealer storing no more than 1,500 waste tires for less than 90 days. If excluded from pernrt,corme'e Parts B and D. If not excluded from peg t requirements complete Parts B.C,and D. PART B—Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facilit Ias � X.XR > 'l 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. ❑ 11 ❑ 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 FacilityMEN ID Yul Req [ement -: ❑ ❑ ❑ PRC§42824-Maior Waste Tire Facility Permit ❑(a)Signs ❑(b)Site Attendant ❑(c)Access ❑ ❑ ❑ PRC§42834-Minor Waste Tire Facility Permit �C �t7353'pax—cmCoTrho ❑ ❑ ❑ PRC§42850(a)-Complies with Terms of Permit ❑ (1)Impermeable Barrier ❑ (2) Approved Vector Plan C] ❑ ❑ 14 CCR§18420(a) -Applicable for Permit r 1 w k 4`CCR -17354 Sfor" 'gd of Yilaste"Tires"Outdoo ❑ ❑ ❑ 14 CCR§18423 -Filing Application for Permit f"B� "»�- ;, ❑ (a)Storage Units ;Recordkeeping`Recjufreinents_,.� ❑ (b)Fire Lanes ❑ ❑ ❑ 14 CCR§ 18432-Operations Plan ❑ (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§18433-Emergency Response Plan ❑ (d)Drainage ❑ (e)Slope/Grade ❑ ❑ ❑ 14 CCR§18447-Records Available ❑ (f)Siting(New Facilities) 14 CCR 17351"=Pire'PreyentlonMoasures ❑ (g)Rim Removal C' t❑ § p (h)Protection from Pyrolytic Oil Runoff ❑(a)Communication Equipment C C C [I(b)Fire Equipment 14 CCR§17356 Iridoor Storage ❑(c)Water Supply Facility compliance with NFPA 231D-1989 ❑ (d)Other Requirements