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t{, ?.0 U 4:D <br /> _- , Waste Tire Survey & Inspection Report suRUEYREQUIREo <br /> • iii%a State of California <br /> CIWatedWa(tewodJo4,, 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 /> TPID- i ---,- Inspectioneo <br /> Site Suffix: Report Q-I <br /> -�- -I --'- ------'�' - - Number: 0� -- <br /> -- -- - - <br /> SWIS i 1 I Inspection Number on the associated Survey form(Page 1) <br /> Number: I Photos Taken If Yes Q No <br /> —I-- - -- -- -- ----- — <br /> Property Owner / I L) <br /> �a_�- ft-q-9 - ,- --- (.?eq�.q 3�- `�`-� , l 3�S S• Cif er .1N� <br /> _ - /�- ! .'iii.._ l -- �/-'...J.'..JJ .il� u .. ♦� <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> Q PRC §42823.5-Cement Manufacturing Plant with Written verification that the facility qualifies for exemption Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ®Excluded Q Unpermitted <br /> Q 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 Q.Major WTF (?5,000 Tires) <br /> Q 14 CC R§ 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 Q Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> V A.irWASTE`'TIRE STORAGE.STrANDARDS r .V' A` " :• <br /> Permit Requirements Q Q 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit I 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a)-Complies with Terms of Permit f 0 (1) Impermeable Barrier 0 (2)Approved Vector Plan <br /> 00 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit 0 (b) Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan 0 (c) Fire District Requirements <br /> Q Q 14 CCR§-18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> Q Q 1 14 CCR§17351 -Fire Prevention Measures 0 (h)-Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply Q Q 1 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments � 1 C _j,1,.�- ,. �, _� � ,,},r �-•�,1_ —_Ll +s „ ` ),r r <br /> L&Wa,� r h.�eZ / ,off <br /> r' �c w�,c_�S Q�Io v� v�1��'Gt tom' JA f_ r Qwo <br /> `�,�o►� � .aveLeenv��c$Rc�e�Q o� i ss�.e r�S <br /> deax-vA c.c.s.&P J 5+n � �''�+�s_ �v �`�i o t4im v-. <br /> �1/(� f form s ► v►e►� �7L <br /> INSTRUCTIONS ON BACK ,t o,,ect: Incorrect: TJX AIM P L E I 2 3 15386 <br /> White Cop CIWM Yellow Copy:Operator Pink Copy.LEA <br />