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� Waste Tire ey & Inspection Re <br /> ■ `'rr SURVEY ■ <br /> State of California REQUIRED <br /> CIWMB 182(New 04/04) <br /> California Integrated Waste Management Board .Inspection Form Page 2 <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- d f Inspection <br /> Site Suffix: t `1 ? ) Report <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: m m Photos Taken 0 Yes 0 No <br /> Property Owner r42 I; <br /> 54'00e-boij O�ktf ll�f P(A (! P� , `�" -/5 D , �5501). � 5�> 5, <br /> Name Y Phone Number Mailing Address City State ZIP Code <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> 0 PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 10 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 0 Excluded Q Unpermitted <br /> j0 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> 0 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises 0 Major WTF (>5,000 Tires) <br /> 0 14 CCR§18420(a)(6)-Auto dismantler storing no more tlian 1,500 waste tires for less than 90 days <br /> 14 CCR 18420 a 7 & e -Tire dealer storin no more'than 1,500 waste tires for 90 da s Minor WTF (500-4,999 Tires) " <br /> 0 § (�O�_) 9 Y I <br /> Part D - Inspection of Waste Tire Facility <br /> V A WASTE TIRE STORAGE STANDARDS V i A 11 <br /> Permit Requirements 0 0 , 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Site Attendant Q (c)Access <br /> 0 PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit Q (1)Impermeable Barrier Q (2)Approved Vector Plan <br /> 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit Q (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> 01 0 1 14 CCR§18433-Emergency Response Plan Q (d)Drainage <br /> Q (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 14 CCR§17351-Fire Prevention Measures Q (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply LQ <br /> Q 14 CCR§17356-Indoor Storage <br /> L (b)Fire Equipment Q.(d)Other Requirements Facility Compliance with NFPA 231D-1989 � <br /> Comments I <br /> 0. o t n-e ✓D P,r� �' � ` ;7��V �{ ewl 0"I c t wyw'r"c) (SCC c(n. <br /> tc t Uc e tc(�2 of 9-I U - irn.s x0cGt n ,I hFs�e Wev-e. <br /> ! I e� r a bra -1 r(tk5 �t ( I� ) <br /> oil "fGl� �r . tri <br /> vJ <br /> i r1 - C�Ir 1? L 1 cc., rC.0 f{'i� t )ct<c. 4�r -/0 c <br /> Z C_'_f`C-t ,t l�o �'�.i '✓ S - 4-t(dN h'/)/ i led -fi'r/ LA]ere Ch a <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (Xj7Q' ,;, Vii, p 1! 15386 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />