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Waste Tire S*ey & Inspection Rer,.. .# LSURVEYREQUIRED <br /> ..a_ State of California <br /> CIWMedWait(New 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 /> - - © ` Inspection <br /> Site 7 9 _ <br /> Site Suffix: �j ` Report I <br /> r Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken Q Yes Q No <br /> Property Owner <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 Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q Excluded lD Unpermitted <br /> Q 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&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 /> 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 /> V A I WASTE TIRE STORAGE STANDARDS VTz�-F <br /> Permit Requirements QCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant 0 (c)Access <br /> Q 0 PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> Q Q PRC§42850(a)-Complies with Terms of Permit 00 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q Q 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 (d)Drainage <br /> Q Q 14 CCR§18433-Emergency Response Plan <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> Q (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available Q (g)Rim Removal <br /> Q Q 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply Q Q 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments Cep— cxww � <br /> INSTRUCTIONS ON BACK Correct: Incorrect:7X*1 :V:I J hit A P, 1 1 2 3 <br /> 15386 <br /> - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA Nc <br />