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Waste Tire Soe & Inspection Re <br /> y p p SURVEY REQUIRED <br /> •,. State of California <br /> ~- CIWMB 182(New 04104) 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- Inspection <br /> Site Suffix: �� (� ` Report I L — if L &1 6 °-1 - S <br /> Number: 1� <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken 0 Yes 0 No <br /> Property Owner <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 0 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 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 days Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> VI A I WASTE TIRE STORAGE STANDARDS V 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 0 (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit 00 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 O (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> 0 0 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 0 1 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment Q (c)Water Supply 0 0 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> �1�Q I121 �✓\ /Iv J cJ Gri_ �t ��f,r Gi N t _�/6;� <br /> n LA <br /> (1-� ®�- tloYlt cin �Jtl ccs IT-[S 7 cXL xa'GL <br /> D:Acn� -J-y - ul 4,4,L:[t,� Lvs-►,,. Z-a-1.s tt;l ct-d-l -L3 ,est. I I<-\-) ril <br /> �� i11G.`l t'fCc1�S. �1. 3 ����� W �,� �'1 L+., a�� ��D✓D-^'j,C:�L <br /> l/ ©� /6 Ywapt i�euh 4-7-� yr—LA' Lo C7z— .-CU ✓ in <br /> t� PK, S I kt OJ&) ✓17vt � l <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: (� �A, M P � E I 2 3 15386 <br /> X <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />