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- r; Waste Tire S vey & Inspection Ret Pt URVEYREQUIRED' <br /> State of California <br /> -~ <br /> CIWMB (New <br /> California IntegratedWaste Management Board Inspection Form - Page 2 <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: l Li © Report I 0 <br /> / Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken 0 Yes Q No <br /> Property Owner <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 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q Excluded 0 Unpermitted <br /> 0 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 Q Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> LV IA WASTE TIRE STORAGE STANDARDS 1 <br /> Permit Requirements 0 Q 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O(a)Signs O (b)Site Attendant O (c)Access <br /> ® Q PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a)-Complies with Terms of Permit O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> ,011 Q 14 CCR§18432-Operations Plan (c)Fire District Requirements <br /> 1 <br /> O (d)Drainage <br /> Q Q 14 CCR§18433-Emergency Response Plan <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> Q 0 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O(a)Communication Equipment Q (c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1 989 <br /> Comments <br /> AAU A" 7ule�' <br /> (� <br /> e itil1. <br /> 1 <br /> INSTRUCTIONS ON BACK E XIA MJPJe 1 � 15386 <br /> White op :CI Yellow Copy:Operator Pink Copy:LEA I t <br />