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Waste Tire Shy & Inspection Rep " <br /> ■ , EQUIRED <br /> State of California <br /> SURVEY R <br /> CIWMB 182(New 04/04) Inspection Form - Page 2 - <br /> _ California Integrated Waste Management Board <br /> Part C - FacilityBLUE OR BLACK INK PENNOW <br /> Information � <br /> rr <br /> K TPID- }} // Inspection (� <br /> " Site Suffix: Report rl -� 1 �• `' �__9. <br /> Number: ----..1.. _- <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: m m Photos Taken (a Yes 0 No <br /> i, <br /> { <br /> t_---- — I I ----- s <br /> Narne Phone Nuti ber Mailing Address State ZIP Code <br /> .., w <br /> Pxer7ipt Btasiness l ylie (Fill iII i 01i able) Permitted Reg I ,r. 1I "ripe <br /> 0 PRC §42823.8 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) 0 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 Minor WTF (500 4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> V A WASTE TIRE STORAGE STANDARDS V A <br /> Perrnii _ J Stu a Itty <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit 0 (a) Signs 0 (b)Site Attendant 0 (c)Access <br /> (,4 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> 0 (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 y Jf <br /> 0 0 14 CCR§18420(a)-Applicable for Permit Q (a) Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q (d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <br /> 0 (e)Slope/Grade <br /> Recardkeepinq Requirement i Q (f)Siting(New Facilities) <br /> Q 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> ^ evention Measures O (h) Protection from Pyrolytic Oil Runoff <br /> •7(a) m^unication Equipment 0 (c)Water Supply 0 0 14 CCR§17356-Indoar StoNagequipment O (d)Other Requirements Facility Compliance with NFPA 231 D 1989 <br /> Comments r <br /> �-r <br /> 71 , <br /> L,. <br /> �j, � r -- <br /> 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X <br /> ■ - ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />