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a <br /> Waste Tire Survey & Inspection Rei, ,,rt SURVEY REQUIRED <br /> State B California <br /> CIWated182 Wa tew04/04) <br /> anage 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- <br /> Inspection <br /> Site Suffix: -7 - 1 Report I - -7 -7 � *p <br /> l Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - - Photos Taken 0 Yes ® No <br /> Property Owner <br /> �/L 1�Gt'�,tnr�r-,� �c�r-�t3i�lG"� G`f3t �.- �.�e-►-iVia�r_�.c�� � E�:`c�''.. �-%� ��v�'� <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> 0 PRC§42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 0 Excluded ® 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 0 Major WTF (_>5,000 Tires) <br /> 0 14 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> 14 CCR 18420 a 7 & e -Tire dealer storingno more than 1,500 waste tires for 90 days ® Minor WTF (500-4,999 Tires) <br /> Part D-Inspection of Waste Tire Facility <br /> V1 A I WASTE TIRE STORAGE STANDARDS V I A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> 41 0 PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> (1)Impermeable Barrier O (2)Approved Vector Plan <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> Q (d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 00 14 CCR§ 18447-Records Available Q (g)Rim Removal <br /> 0 0 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment 0(c)Water Supply 0 0 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> - --- --- 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� )L r�� I? 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />