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FORM NO.M-105548-CIWMB M12 5004 519 9 8 7 6 51:-' <br /> Waste Tire Survey & Inspection Re ort <br /> 5871 <br /> p p SURVEY REQUIRED) <br /> State of California i <br /> CIWMB 182(Waite <br /> eManag) 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- Inspection - - - - -- -- -Site Suffix: \ Cj C, �- L 1 Report I ']> _ t7 C) / Q <br /> Number: b J <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken Q Yes Q No <br /> Property Owner - - - — - -- <br /> �9�t.hr� -L-Z" <br /> �7�- 3b�� ('>�loi E < (�w�y�o� l� t✓Z Li�� �� �SZ3 <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 Q Unpermitted <br /> Q 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water 8 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 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> Lo 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 /> A <br /> WASTE TIRE STORAGE STANDARDS V A — - ` <br /> Permit Requirements Q Q 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit - 0 (a)Signs O (b)Site Attendant Q (c)Access_ <br /> ® Q PRC§42834-Minor Waste Tire Facility Permit I O O 14 CCR§17353(0)-Vector Control <br /> _ O (1-) <br /> Impermeable Barrier Q (2)Approved Vector Plan <br /> O OPRC§42850(a)-Complies with Terms of Permit QQ <br /> 14 CCR§17354-Storage of Waste Tires Outdoors - <br /> Q O 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q O 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> Q Q 14 CCR§ 18432-Operations Plan O (c)Fire District Requirements <br /> Q Q 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> - O (e)Slope/Grade <br /> Recordlkeeping Requirement O (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available O (g)Rim Removal <br /> Q Q 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment Q (c)Water Supply Q CC 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231D-1989 ` <br /> Comments <br /> _I Ile <br /> __�b�ti�-- V `V�C•c.��t71^ -ill -{,tiu�-- --�� �� �L� <br /> lit <br /> ;, a,•. .. - 15386 <br /> INSTRUCTIONS ON BACK Correct Incorrect + A'.tt►h P L 1 2 3 <br /> White CoDv-CIWMB Yeilow Copy:Operat^r Pink Copy:LEA <br />