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Waste Tire vey & Inspection Re <br /> ■ <br /> Lr—.7.r—n,.a <br /> State of CaliforniaNSURVEY REQUIREDCIWM8182(New04104) Ins ection -f=orm - Page2 <br /> Integrated Waste Management Board Inspection <br /> C - Facility Information BLUE OR BLACK'INK PEN <br /> Business Profile Inspection Details , <br /> Site - C _ I Inspection <br /> Site Suffix: i Report <br /> Number: m 1 d <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: — m Photos Taken (D Yes O No <br /> I <br /> Property Owner <br /> Name Phone Number Mailing Address City State ZIP Code <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> Q PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) O Excluded (K)i Unpermitted <br /> Q 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 /> Q 14 CC R§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days J <br /> Q 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days Minor WTF (500--4 999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> VA WASTE TIRE STORAGE STANDARDS <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q O PRC§42824-Major Waste Tire Facility Permit I 1 Q (a)Signs Q (b)Site Attendant Q (c)Access <br /> u Q PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> O Q 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 /> O Q 14 CCR§18420(a)-Applicable for Permit <br /> Q (a)Storage Units <br /> . 0 Q 14 CCR§18423-Filing Application for Permit Q (b)Fire Lanes <br /> Q 0 14 CCR§18432-Operations Plan Q (c)Fire District Requirements <br /> O Q 14 CCR§18433-Emergency Response Plan Q (d)Drainage <br /> Q (e)Slope/Grade <br /> Recordkee ing Requirement Q (f)Siting(New Facilities) <br /> 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 01 0, 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ( } d E` A"M PJ E'J 1 1 2 3 15386 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />