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City/County Wasteire Survey and Inspection Repo, < �t Mailino Address 2" _� � (�ry ```—� ,t _Fes.1 7c . Dy Phone Number State of California CIWMB-54(10/03) PART A—General Information/Survey Page of �x y r. ), �.�r,,�. INSPECTION I SITE VISI,11 Type(Check one) outine ❑ Re-inspection ❑ Complaint ❑ Observation ❑CIWMB Referral ❑CHP Referral ❑Other: Facility SWIS: Inspected by: Time In: Date: Regulatory Sta s: File No. TPID: 1 2/I4CG`i—v r ❑County/City C �j JU;f. ❑Permitted S Excluded❑ Exempt❑Unpermitted Hauler ID: Code: Time Out: Total Time: Operational Status: E]State Local: M Active E]Closed F] Inactive ElPlanned Business/Facility Name: Tire Count: TIT \,_J UJ )O rA� �j��? [}Passenger❑Altered[]Truck E] OTR Address: n Phone: Storage Type: 1 tf-2-0 1,J ��r c A"le- l��-t 9SZ v [I Outdoor El Indoor M Container Owner: Insp or(Please�Priintt): f Business Rep: �t-,rr�lI �;c�C�� Title: �rF:�r� r-1 - V,ct r— 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) EJTire 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 ",,,.,� 'I HAULING AND' IF NCsyREQU �MENTS'F V, A I c y,,., ❑ ❑ ❑ 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 k :" .,I r" 1KRt Permits Requirements [ E_ C 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 [ I [ I [ 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 E_ I E_ [ 14 CCR§17354-Storage of Waste Tires Outdoors Recordkeeping Requirements ❑ (a)Storage Units ❑ ❑ ❑ 14 CCR§ 18432—Operations Plan ❑ (b) Fire Lanes El (c)Fire District Requirements ❑ ❑ ❑ 14 CCR§ 18433—Emergency Response Plan ❑ (d)Drainage ❑ ❑ ❑ 14 CCR§ 18447—Records Available ❑ (e)Slope/Grade F1 E= El ( 14 CCR§17351 -Fire Prevention Measures ❑ (g Siting(New Facilities) g)Rim Removal ❑ (a)Communication Equipment ❑ (h)Protection from Pyrolytic Oil Runoff ❑ (b) Fire Equipment [ I [ I [ 14 CCR§17356 -Indoor Storage ❑ (c)Water Supply ❑ (d)Other Requirements Facility compliance with NFPA 231 D-1989