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atntogratedWa <br /> Waste Tire ey & InspectionReay. c SURVEY REQUIR■ State of Californiacp� ---- -------CIWMB102(New04/04) Inspects®n 1 ®rlll - Page 2ste Management Board <br /> Part C - FacilityInformation _- _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> _ Inspection <br /> Ste Suffix: � � � 3 � � I Report I <br /> Number: <br /> Inspection Number on the associated Survey form(Page 1) <br /> SWIS <br /> Number: Photos Taken Q Yes ® 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 O Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> O PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) (J0 Excluded Q Unpermitted <br /> O 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> O 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 /> Q 14 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> ® Minor WTF (500-4,999 Tires) <br /> IS 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days <br /> Part D - Inspection of Waste Tire Facility <br /> V' A WASTE TIRE STORAGE STANDARDS_ j V A __ <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q 0 PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Site Attendant Q (c)Access <br /> O O O O 14 CCR§17353(a)-Vector Control <br /> PRC§42834-Minor Waste Tire Facility Permit 2 Approved Vector Plan <br /> Q (1)Impermeable Barrier Q ( ) pp <br /> PRC§42850(a) Complies with Terms of Permit O O 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O 0 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> O Q 14 CCR§18423-Filing Application for Permit Q (b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan Q (c)Fire District Requirements <br /> Q (d)Drainage <br /> O Q 14 CCR§18433-Emergency Response Plan Q (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> O Q 14 CCR§18447-Records Available Q (g)Rim Removal <br /> O Q 14 CCR§17351-Fire Prevention Measures Q (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply 0 . 0 . 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments c <br /> a.J <br /> 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ') A ICY (� <br /> --- W.-_- <br /> ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />