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Waste Tireq&ey 8t InSpeCtlOn R SURVEY REQUIRED ■ <br /> State of California <br /> CIWMB182(New 04/04) Inspection Form - Page 2 --- - --_-- --------- _- -- <br /> California Integrated Waste Management Board <br /> Part C- Facility-Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI <br /> - <br /> Ispection <br /> Site S n _ <br /> Site Suffix: Report <br /> I I I <br /> ' Number: <br /> SWIS Inspection Number on the associated Survey form(Pagel,) <br /> Number: Photos Taken 0 Yes No <br /> Property Owner <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 /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® Excluded 0 Unpermitted <br /> 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 than 1,500 waste tires for less than 90 days <br /> 14 CCR§18420 a 7 & e -Tire dealer storing no more than 1,500 waste tires for 90 days 0 Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> VI A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> 0 0 PRC§42824 f Major Waste Tire Facility Permit O (a)Signs O(b)Site Attendant O (c)Access <br /> 0 0 PRC§42834 Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> 0 0 O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> PRC§42850 a)-Complies with Terms of Permit <br /> 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§181 20(a)-Applicable for Permit 0 (a)Storage Units <br /> 0 0 14 CCR§18 23-Filing Application for Permit O (b)Fire Lanes <br /> 0 0 14 CCR§1 32-Operations Plan O (c)Fire District Requirements <br /> 0 0 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement O (t)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available O (g)Rim Removal <br /> 0 0 1 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment O (c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> <5 eee, <br /> .d5 -Fms'm <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �Jl M P 15386 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA Nil ■ <br />