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E :.fit;:: Waste Tire Survey & Inspection Report SURv QUI D <br /> State of California <br /> CIWMat62(Hew 04104) <br /> —9. Inspection Form - Page 2 <br /> al am Integrated Waata Management Board <br /> Part C-Pa:111ty Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- T t Inspection I I <br /> t Site Suffix: T 3 1 ' O (� r} Report <br /> �p_ _ _til Number: <br /> SWIS j I Inspection Number on the associated Survey form(Page f) <br /> Number: ; Photos Taken O Yes 0 No <br /> i t <br /> Property Owner <br /> Exempt Business Type (Fill it applicable) Permitted Regulatory Status(Fill one) <br /> O PRC§42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption O Permitted O Exempt <br /> Excluded Business Types(Fill if applicable) N/A- <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) O Excluded O Unpennitted <br /> O 14 CCR§18420(a)(2)-Agricultural<5,000 fires incapable of holding water 8 used for bumpers or ballast Facility Type(Fill one) <br /> O 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises O Major <br /> p rWT (?5,000 Tires) <br /> O 14 CCR§18420(a)(6)-Auto dismantler staring no more than 1,500 waste tires for less than 90 days /V <br /> O 14 CCR§18420(a)(7)8(e)-Tire dealer storing no more than 1,500 waste tires for 90 days _ <br /> O Minor lAfTF (500-4,999 Tires) <br /> Part D-Inspection of Waste Tire Facility <br /> V A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> O O PRC§42824-Major Waste Tire Facility Permit 0(a)Signs 0(b)Site Attendant 0(c)Access <br /> O tO PRC§42834-Minor Waste Tire Facility Permit .00 1 14 CCR g 17353(a)-Vector Control <br /> Q(1)Impermeable Barrier 0(2)Approved Vector Plan <br /> O O PRC§42850(a)-Complies with Terms of Permit O O 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O O 14 CCR§18420(a)-Applicable for Permit Q(a)Storage Units <br /> O O 14 CCR§18423.Filing Application for Permit O(b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan 0(c)Fire District Requirements <br /> 0(d)Drainage <br /> 01 014 CCR§18433-Emergency Response Plan <br /> 0(e)Slope/Grade <br /> Recordkeeping Requirement Q(f)Siting(New Facilities) <br /> O O 14 CCR§18447-Records Available Q(g)Rim Removal <br /> O O 14 CCR§17351-Fire Prevention Measures O(h)Protection from Pyrolytic Oil Runoff <br /> O(a)Communication Equipment Q(c)Water Supply O O 14 CCR§17356-Indoor Storage <br /> 0(b)Fire Equipment Q, (d)Other <br /> �Requirements J Facility Compliancewith NFPA 231D-1989 <br /> Comments �c t, �1`4�f` Gi�d� l eQ y C_ �+t � e -�r <br /> ea az fit` <br /> and r-plazin nu ZPests hLr 3 o►, abe - <br /> OWLf?.Vns Vk1alA bt dyet til -/o O�Ak t- -e @ <br /> ri e-s�s �Ie_ F- V.Pd10 _J-1eAyU1-1- X Woe 93ga <br /> - 15386 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:Rog EXAMPLE 1 2 3 ■ <br /> ■ <br /> ■ White Copy:CNYMB Yellow Copy:Operator Pink Copy:LFA, <br />