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1 <br /> rEo Waste Tire S vey & Inspection Rep t SURVEY REQUIRED <br /> YY�f,t State of California <br /> CIWMedWast(New anage Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> -7--Part-C---Facility-Information - BLUE OR-BL-AGK-INK-PEN <br /> Business Profile Inspection Details <br /> TPID- L g Inspection ? <br /> Site Suffix: V Z g U Report I — I 7 -7 b J <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken Q 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 O permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) A 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 O Major WTF (_>5,000 Tires) <br /> 0 14 CC R§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 I `A WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements . Q Q 14 CCR§17352-Site Security <br /> 0 O PRC§42824-Major Waste Tire Facility Permit O (a)Signs O(b)Site Attendant O (c)Access <br /> 0 O PRC§42834-Minor Waste Tire Facility Permit O O 14 CCR§17353(a)-Vector Control <br /> 0 O PRC§42850(a)-Complies with Terms of Permit O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> Q 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q O 14 CCR§18420(a)-Applicable for Permit 10 (a)Storage Units <br /> 0 Q 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> O 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> O 0 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement O (f)Siting(New Facilities] <br /> O Q 14 CCR§18447-Records Available O (g)Rim Removal <br /> O Q 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment O (c)Water Supply Q O 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments Co <br /> ,�( � _ <br /> INSTRUCTIONS ON BACK. Correct:* Incorrect: VU F, �; IAIPI �L 1I �: 3 15386® F . <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> - ----- ----------- — ------------- -------- <br />