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Waste Tire Spey & Inspection Reps SURVEY REQUIRED ■ <br />CIWState of California <br />MB 182 (New 04/04) --- <br />Californiaoia Integrated Waste Management Board Inspection Form -Page 2 -'+- <br />Part C - Facility Information BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />SWIS <br />Number: <br />Property <br />Inspection <br />Report I - <br />Number: <br />Inspection Number on the associated Survey form (Page 1) <br />Photos Taken Q Yes Q No <br />---__ .J L I I -- _-- — --� <br />Phone Number Mailing Address C%i "f' �n -? <br />Exempt Business Type (Fill if applicable) <br />''t grihiCted Regulatory Status (Fill one) <br />P <br />0 PRC § 428215 - Cement Manufacturing Plant with written verification that the facility qualifies for exemption permitted 0 Exempt <br />Excluded Business Types (Fill if applicable) <br />O PRC § 42808 - Permitted Solid Waste Facility (Landfill, Transfer Station) O Excluded O Unpermitted <br />O 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 />O 14 CCR § 18420 (a) (6) - Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br />Q 14 CCR § 18420 (a) (7) & (e) -Tire dealer storing no more than 1,500 waste tires for 90 days O Minor WTF (500 - 4,999 Tires) <br />Part D - Inspection of Waste Tire Facility <br />V A WASTE TiRE STORAGE STANDARDS V A <br />Q <br />O <br />PRC § 42824 - Major Waste Tire Facility Permit <br />O <br />O <br />PRC § 42834 - Minor Waste Tire Facility Permit <br />O <br />O <br />PRC § 42850(a) - Complies with Terms of Permit <br />O <br />O <br />14 CCR § 18420(a) - Applicable for Permit <br />O <br />O <br />14 CCR § 18423 - Filing Application for Permit <br />O <br />O <br />14 CCR § 18432 - Operations Plan <br />O <br />O <br />14 CCR § 18433 - Emergency Response Plan <br />Q (f) Siting (New Facilities) <br />1 <br />Recordkeeping Requirement <br />O <br />O <br />14 CCR § 18447 - Records Available <br />i 0? <br />014 <br />CCR § 17351 - Fire Prevention Measures <br />Q (a) Communication Equipment Q (c) Water Supply <br />Q (b) Fire Equipment 0-(d-) Other Requirements <br />Comments <br />t'0 O <br />7 52 .. it..ac: twity <br />14 CCR § 17352 <br />XX, <br />Yellow Copy: Operator <br />Q (a) Signs Q (b) Site Attendant Q (c) Access <br />0 0 <br />14 CCR § -1734:.3(a) - hector Control <br />Pink Copy: LEA <br />Q (1) Impermeable Barrier Q (2) Approved Vector Plan <br />0:0 <br />14 CCR § 17354 - Storage of Waste, Tires Outdoors <br />Q (a) Storage Units <br />Q (b) Fire Lanes <br />Q (c) Fire District Requirements <br />Q (d) Drainage <br />Q (e) Slope/Grade <br />Q (f) Siting (New Facilities) <br />1 <br />Q (g) Rim Removal <br />Q (h) Protection from Pyrolytic Oil Runoff <br />.00 <br />14 CCR § 17 356 - Indoor Storage <br />Facility Compliance with NFPA 231D-1989 <br />--'•.i —1 <br />■ <br />INSTRUCTIONS ON BACK [Correct:Incorrect: <br />White Copy: CIWMB <br />XX, <br />Yellow Copy: Operator <br />A1�2Opi e <br />15386 <br />® <br />■ <br />Pink Copy: LEA <br />1 <br />— <br />■ <br />INSTRUCTIONS ON BACK [Correct:Incorrect: <br />White Copy: CIWMB <br />XX, <br />Yellow Copy: Operator <br />A1�2Opi e <br />15386 <br />® <br />■ <br />Pink Copy: LEA <br />