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r►,�f ]9�d�tl�lf � <br /> M.- Waste Tire Svey & Inspection Rer 't SURVEY REQUIRED <br /> hm'-it7s State of California <br /> CIWMB 182 eMan04104) <br /> Management <br /> Inspection 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 /> - - -� - --- - - <br /> TPID- InsP ection Q <br /> Site Suffix: 1 3 3 ! g l - D l Report I U O <br /> - - -' Number. -- -- ) -- - -1 <br /> SWIS I I Inspection Number on the associated Survey form(Page 1) <br /> Number: I —i - � j , l_ - _� Photos Taken 1@1 Yes 0 No <br /> Property Owner _ <br /> tal JV)0 0Mer �l�ha>� o2bq-36.�ol3b _ 1 r1,. cJ1ffc)6ee Ln Lcc�l Co. q d4x� <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> 0 PRC §42823.5-Cement Manufacturing Plant.with written verification that the facility qualifies for exemption 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 0-PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 0 Excluded 41 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 C CR§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 da Minor WTF (500-4,999 Tires) <br /> 0 §__�_Z_�_) 9 Ys <br /> Part D- Inspection of Waste Tire Facility <br /> V A WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit ] _. O (1) Impermeable Barrier O (2)Approved Vector Plan <br /> 0 0 1 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit O (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> 0 0 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement O (f)Siting(New Facilities) <br /> 0 0 14 CCR§ 18447-Records Available O (g)Rim Removal <br /> 0 0 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment O (c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> O (b) Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments � 00�Drn�ffJY�� �� P <br /> INSTRUCTIONS ON BACK orre t: Incorrect: �� 15386 <br /> EXA � P �. � : t 23 <br /> White C y:CI Yellow Copy:Operator Pink Copy:LEA <br />