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® �sl Waste Tire S ey & Inspection Repo SURVEY REQUIRED <br /> State of California <br /> ' =I CIWMB182(New 04/04) Inspection Form - Page -- <br /> California Integrated Waste Management Board <br /> Part C - Facilit Information BLUE OR BLACK INK PEN <br /> f <br /> Business Rey <br /> f TPID- Inspection _ <br /> Report <br /> Site Suffix: <br /> Number: <br /> _ <br /> SWIS m Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken Q Yes @ No <br /> Property Own <br /> l_„ )(L 1' '/. <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 facility qualifies for exemption O permitted O Exempt <br /> Excluded Business Types(Fill if applicable) <br /> O PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) O Excluded O Unpermitted <br /> 0 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> 0 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises O Major WTF (>5,000 Tires) <br /> 0 14 CC R§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> O 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 /> V ,.A WASTE TIRE STORAGE STANDARDS V Al <br /> W1111101" <br /> , 6""1"" � .. , <br /> I' � S1i <br /> Q 0 PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant O (c)Access <br /> O O PRC§42834-Minor Waste Tire Facility Permit 1 a 14 CCR§17353(a)-Vector Conm)i <br /> 0 O PRC§42850(a)-Complies with Terms of Permit 0 (,1) Impermeable Barrier 0 (2)Approved Vector Plan <br /> Q 0 :, 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O Q 14 CCR§18420(a)-Applicable for Permit <br /> 0 (a)Storage Units <br /> O O 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> 0 O 14 CCR§18433-Emergency Response Plan 0 (d) Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> 0 (f)Siting(New Facilities) <br /> O O 14 CCR§ 18447-Records Available 0 (g) Rim Removal <br /> 0 0 14 CCR§17351 -Fire Prevention Measures 0 (h) Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply 0 C14 CCR 17355-Indoor Storage <br /> e <br /> 0 (b) Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments%!f /C)!` ) t4 Gr r?tJ' E'�i' �`Cll ' PL11� � A �'' <br /> r . tv <br /> J / <br /> of Oil 11:r 0(bu) AI. ` 0yl .%) at'r uiC' <br /> ! j, <br /> !A�L) <br /> _., <br /> INSTRUCTIONS ON BACK Correct:` Incorrect: X �,. 9: ; ; A. 1.+ �_ f= 15386 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />