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+ eea,_ Waste Tire ey & 'Inspection Re, rt SURVEYREQUIREO <br /> 4i+_:� State of California <br /> CIWMB182(New 04/04) nspection •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 /> TPID- i I I I Inspection <br /> 1 � Lot1 <br /> Report <br /> I/ _ � 10gg i-- r—, <br /> Site Suffix: L._� `_ I_ __J � Number: I I I / I <br /> L— L__J <br /> SWIS I f Inspection Number on the associated Survey form(Page 1) <br /> Number: I A_j - f _1 _1 I Photos Taken Q Yes ® No <br /> Property Owner <br /> erne Phc!-;e Nuinae :(e_'nc,a:G� :Sd-- - —- - -- `Siale--LL-I CoCa <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 /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® Excluded Q 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 /> Q 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises Q Major WTF (>5,000 Tires) <br /> i <br /> Q 14 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <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 /> V A WASTE TIRE ST i 6E STANDARDS V A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O (a)Signs Q (b)Site Attendant O (c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit Q Q 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a)-Complies With Terms of Permit O (1) Impermeable Barrier Q (2)Approved Vector Plan <br /> Q 01 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit <br /> O (a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q Q 14 CCR§18433--Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement <br /> O (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available O (g)Rim Removal <br /> Q Q 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment O (c),Water Supply 1 Q 10 1 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments,, tU S Pew y► a <br /> l7�c Ch i o �S _ �'wl s o V� �c`�� ►'_ <br /> l u-e-arS <br /> X20 to o A7 os� a F 4k -tires et �'!�0 oh A- -�P_ fir res-cd-e_ <br /> VV ere be-r4- r&v-im1(,.s a w rW_(1_. <br /> nl� ✓i01a�1�en s 1��fecL o <br /> 15386 <br /> INSTRUCTIONS ON BACK Co ect. ncorrect: X a M P L E Z 2 3 <br /> White Copy Cl Yellow Copy:Operator Pink Copy:LEA ® . <br />