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s <br /> . Waste Tire S rvey & Inspection Report [�p <br /> 77t Stato of Califomia 1"RVEY -""" `� ■ <br /> ClWMB 182(Now 04/0A{ Page <br /> 2 <br /> Call(ornla Integrated Waste Management Board Inspection Form �- <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile _ _1-inspection Details <br /> TPID- Inspection <br /> site suffix: ` rl Report <br /> t Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: j Photos Taken 0 Yes 0 No <br /> Property Owner <br /> Exempt Business Type (Fill if applicable) __ I Permitted Regulatory Status (Fill one) <br /> ;0 PRC §42823.5--dement Manufacturing Plant with written verification that the facility qualifies for exemption 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 10 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 0 Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> _. ._. ---- ...--- ----- <br /> A 1 A$ TIROS7fJ13At3E 8TANDARgS V A <br /> Permit Requirements 0 0 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 /> 0 0 . PRC§42834-Minor Waste Tire Facility Permit 10_ 0 14 CCR§17353(a)-Vector Control <br /> 00 j PRC§42850(8)-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 /> 0 0 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit ! ! 0 (b)Fire Lanes <br /> i <br /> 0 0 14 CCR§18432-Operations Plan ! 0 (c) Fire District Requirements <br /> 0 0 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> 10 0 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 0 0 14 CCR§17351-Fire Prevention Measures 0 (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply I 0 f 0 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:X ( E: XIAMIPILIEI 1112 3 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />