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T ( Waste Tire SdOey & Inspection Rept <br /> r State of California SURVEY REQUIRED <br /> CIWMB 182(New 04/04) <br /> California Integrated Waste Management Board Inspection Form Page 2 <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> InspecttAC w <br /> TPID- Inspection Site Suffix: Report ETT_ <br /> iNumber:SWI -_._.- --_-� <br /> Num Inspection Number on the associated Survey form(Page 1) <br /> ITJ=Number: Photos Taken 0 Yes 0 No <br /> 7�ame <br /> Phone NurnberMailing Address (ity State7 ZIP Code <br /> r11 1. r,. ": �w3u �" q^,J `+a$ ,P�t � Pa°f"t �, " f`p'��,1 ±,r�r"� ., ..n ;,rar a„ M ref �'""" ✓ht�o � p � ^w, <br /> 0 PRC §42823.5 Cement Manufacturing Plant with written verification that the facility qualifies for exemption <br /> 0 Permitted Q Exempt <br /> Exclud,d Sus cress Types(Fill if applicable) <br /> I0 PRC§42808 Permitted Solid Waste Facility(Landfill,Transfer Station) 0 Excluded 0 Llnpermitted <br /> 14 CCR 18420 a 2 Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast r"" }" "' <br /> 10 § ( )( )- 9 P g pwmri^`N�!P• � �"'w�lf"'� � <br /> is <br /> r 0 14 C CR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises <br /> 0 Major WTF (?5,000 Tires) <br /> I0 14 CC R§184.20(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> I® 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 /> V A WASTE TIRE STORAGE STANDARDS ' V A <br /> I - <br /> w <br /> . a y ,w n w �P'� rY!�,�_.,."^.,J ada..'V✓«�a ;`��„''."�5^�:�ly Y,± 1,�>. x�P'aHa;,,�1 '—y"w, +�+.f r,��� "'"^"�*,��n'�wlx�e�; �,� In�r,���>rr da ,., �.�.0 r " <br /> J0 0 PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Slte Attendant Q (c)Access <br /> 01 0 PRC§42834-Minor Waste Tire Facility Permit <br /> O (1) Impermeable Barrier 0 (2)Approved Vector Plan <br /> 0I 0 PRC§42850(a)-Complies with Terms of Permit <br /> OR <br /> 0 0 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units 4 <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 <br /> O (d) Drainage <br /> O (e)Slope/Grade <br /> Siting(New Facilities) <br /> 00 14 CCR§18447 Records Available Q (g) Rim Removal <br /> N ��I�� �y � Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment Q c Water Su I �� %✓�y <� " l�ti�a7 �7;a r"r�ait �i�ri a <br /> ( ) PP Y �+.,, .��',,�tl �:L��i ,... o� a• ', �� � <br /> Q (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> f <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A M F 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />