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7 <br /> ■ `l Waste Tire Survey & Inspection Report SURVEY REQUIRED . <br /> i n., Strte of Ca1if-1. <br /> C1WMB 18 1. WJ 11 Inspection Form - Page 2„ <br /> Califomla lnt lINIVI A Waste MOZ04)rots Boats <br /> Part C-Facility Information ..BLUE OR BLACK INK PEN <br /> Business Profile- Inspection Details <br /> TPID- '- --(— Inspection <br /> L' I D I I <br /> Site Suffix: _r 2 I '1 ! 3 i . L I�J -T I��� Report I j_l8_ <br /> SWIS { _( ,-�- (( - I y i I I Number. Inspection Numberon the associetedS ervu y�(Page f) <br /> Number: ' I 11 L , 1- I Photos Taken Yes 0 No <br /> Property Owner <br /> 1. "es _ 1r1[,r{/Ir (2pJ r 1.22/ l0�- to"- 44" .4K'A4AQCva C4 QS <br /> ivamS .. -- F:.uae rJumosr ka"!'ngAddniss -- - -Ci;y , •,.• 21'Co...-. <br /> Exempt Business Type (Fill'rf 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 Statim) 0 Excluded 0 Unpermitted <br /> 0 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water 8 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 (1 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 /> 14 CCR§18420 a 7 & e Tire dealer storing no more than 1,500 waste tires for 90 d 0 Minor WTF (500-4,999 Tires) <br /> ( )_(_) O 9 _y _. <br /> Part D-Inspection of Waste Tire Facility <br /> V A .WASTETIRE STORAGE STANDARDS V A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit 0(a)Signs 0(b)Site Attendant 0(c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR,§17353(a)-Vector Control <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit O(1)Impermeable Barrer 0(2)Approved Vector Plan <br /> 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit 0(a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit 0(b)Fire Lanes <br /> 0 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 /> Recordkee ing Requirement <br /> 0(f)Siting(New Facilities) <br /> 0 0 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 0 14 CCR§17356-Indoor Storage <br /> 0(b)Fire Equipment 0(d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments nGr� v'G� /•1 --�� ,�� -� / A <br /> 'l�/a�J p5.►/� � G1�J�i les �a'' ���1i1/0 t I?'Yt rs'i'fe ��I//f/f�P�.J�. <br /> { <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> ■ EXitAhPLEi 223 15386® ■ <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />