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Waste Tire SOvey & Inspection ReW <br /> $11FiE'1fQUIRD <br /> State of California I <br /> CIWMB182(Now 041D4) Inspection Form - Page 2 <br /> Callfofnle Integrated Waste Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: p '�. Q '� p , Report I LI t <br /> Number: ` l <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: <br /> Photos Taken ® Yes O No <br /> Property Owner <br /> LJJ_iZ t <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 O Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q Excluded ® 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 0 Major WTF (?5,000 Tires) <br /> Q 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 ® Minor WTF (500 4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> ;f' .. .. <br /> Permit Requirements JQ Q 14 CCR§17352-Site Security <br /> 0! Q PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Site Attendant <br /> Q (c)Access <br /> ® Q PRC§42834-Minor Waste Tire Facility Permit 9 Q 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a) Complies with Terms of Permit Q (1)Impermeable Barrier Q (2)Approved Vector Plan <br /> ® Q 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 ' 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q 14 CCR§18423-Filing Application for Permit Q (b) Fire Lanes <br /> 0 Q 14 CCR§18432-Operations Plan O (c) Fire District Requirements <br /> 0 <br /> Q (d)Drainage <br /> Q 14 CCR§18433-Emergency Response Plan <br /> _ O (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> I <br /> 0 Q 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 114 CCR§17351-Fire Prevention Measures O (h) Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply 010 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments y ` <br /> als <br /> 0V\ eC� 515 tEGtl�y , D ,S Uei('e�f' o <br /> Qtr. v C LXt 5 1�h ` 1Mb C� t 5 .L t �-c5 t�� CA- 't►n^--t '('O .i 1 <br /> Lr a^ �-k\r t,��"C� v�.t�,L� � ivy c�\�� ` LX ���`n.c� \C\k34_ <br /> \► PLL ��Jk S ` ., <br /> t _ _ <br /> ((���5k�t;� �� L�.��11.•� \��\ w�-s�-�- l►��s� �`�-t,�t�.c.,t C�r.�c«-e�C' �. <br /> t�,��t-� tY_ "'Ra V-C&A— <br /> _ _...� ... __ 15386 <br /> INSTRUCTIONS ON BACK ', A M I L EI 2 ; � 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> D. 2 k 3 <br />