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Waste Tire <br />G State of California <br />CIWMB 182 (New 04/04) <br />California Integrated Waste Management Boar <br />Part C - Facility Information <br />TPID - <br />Site Suffix: <br />SWIS <br />Number: <br />lbiey & Inspection Ret <br />Board Inspection Form -Page 2 <br />q1 r1l I1 / <br />Inspection <br />Report <br />Number: <br />Photos Taken <br />SURVEY REQUIRED <br />BLUE OR BLACK INK PEN <br />JOA -L71 <br />Inspection Number on the associated Survey form (Page 1) <br />O Yes ® No <br />.._� . , . I l a i <br />Name Phone Number Mailing Address City State ZIP Code <br />Q PRC § 42823.5 - Cement Manufacturing Plant with written verification that the facility qualifies for exemption O permitted 0 Exempt <br />0 <br />O � <br />PRC § 42824 -Major Waste Tire Facility Permit <br />Q <br />Q <br />PRC § 42834 -Minor Waste Tire Facility Permit <br />14 CCR 153{f7 <br />0 (1) Impermeable Balder 0 (2) Approvud ?lin <br />O <br />O <br />PRC § 42850(a) - Complies with Terms of Permit <br />_,:R �4-far�ie 6VVst�ts ?r7utdr <br />O <br />O <br />14 CCR § 18420(a) - Applicable for Permit0 <br />(a) Storage Urtits <br />O <br />O <br />14 CCR § 18423 - Filing Application for Permit <br />0 (b) Fire Lanes <br />O <br />O <br />14 CCR § 18432 - Operations Plan <br />0 (c) Fire District Requirements <br />0 (d) Drainage <br />O <br />O <br />14 CCR § 18433 - Emergency Response Plan <br />0 (e) Slope/Grade <br />Recordkeeping Requirement <br />0 (f) Siting (New Facilities) <br />O <br />O <br />14 CCR § 18447 - Records Available <br />0 (g) Rim Removal <br />0 <br />0 <br />14 CCR § 17351 - Fire Prevention Measures <br />0 (h) Protection from Pyrolytic Oil Runoff <br />0 (a) Communication Equipment 0 (c) Water Supply <br />Q Q 14 CCR § 17356 - Indoor Storage <br />0 (b) Fire <br />Equipment 0 (d) Other Requirements <br />Facility Compliance with NFPA 231 D-1989 <br />Comments <br />�, � 15386 <br />INSTRUCTIONS ON BACK Correct; Incorrect. i- �/ E A P o E 2 <br />■ - - -1 ■ <br />White Copy. CIWMB Yellow Copy: Operator Pink Copy: LEA <br />