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Waste Tire Sur - %-O%y & Inspection Repo <br /> State of California SURVEY REQUIRED <br /> hfar.- Inspection Form Page 2 <br /> CIWMB 182(New 04/04) -- <br /> Caallifornia 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: ` O <3 Q q, 3 v ` Report <br /> Number: b <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken O Yes O No <br /> Property Owner <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> O PRC §42823.5-Cement Manufacturing Plant with written verification that the`acility qualifies for exemption O 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 Ovate,^ used for bumpers or ballast Facility Type(Fill one) <br /> O 14 CCR§ 18420(a)(4)-Tire retreading facility with no more than 3,000 wase;ares on premises O Major WTF (>5,000 Tires) <br /> O 14 CCR§ 18420(a)(6)-Auto dismantler storing no more than 1,500 waste? es for less than 90 days <br /> O 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste 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 /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> O 0 PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> ® 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> O 0 PRC§42850(a)-Complies with Terms of Permit 0 (1) Impermeable Barrier 0 (2)Approved Vector Plan <br /> 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O 0 14 CCR§18420(a)-Applicable for Permit <br /> 0 (a)Storage Units <br /> O 0 14 CCR§ 18423-Filing Application for Permit 0 (b) Fire Lanes <br /> O 0 14 CCR§ 18432-Operations Plan 0 (c)Fire District Requirements <br /> 0 0 14 CCR§ 18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> Q (f)Siting (New Facilities) <br /> O 0 14 CCR§18447-Records Available 0 (g) Rim Removal <br /> O 0 14 CCR§17351 -Fire Prevention Measures 0 (h) Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply 0 0 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> v�.v'� ci\ .c y� (��`� `\Z`� \ �' \\A <br /> • �t>v�`GL C�� GL �����-.P 4-Lt.�� LJ u..5'�'L `�� �,� T� �i�L uv�pJ..t_ l,J�2.5�"-C-- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E a N, E 1 , 15386 <br /> ® White Copy.CIWMB Yellow Copy G:e;,r Pink Copy:LEA <br />