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State Tire ey & Inspection Ret SURVEY REQUIRED <br /> >1 CIWMB 182(New 04/04) <br /> California Integrated Waste 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: ` 1► 5 �p © Report <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken O Yes 0 No <br /> Property Owner <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> O 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 ® 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 O 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 /> VI A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 O 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> O PRC§42834-Minor Waste Tire Facility Permit (5 O 14 CCR§17353(a)-Vector Control <br /> O O PRC§42850(a)-Complies with Terms of Permit 0 (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O O 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> O O 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> O O 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> O Q 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> O Q 1 14 CCR§17351-Fire Prevention Measures 0 (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> INSTRUCTIONS ON BACK [Correct. Incorrect: JE XIA MIPILIEI I l 2 3 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA N&J <br />