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Waste Tire S#ey & Inspection Re t SURVEY REQUIRED <br /> State of California <br /> CIwMed Waste <br /> eManag) Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> tiiness Profile Inspection Details <br /> TPID- , i <br /> Inspection <br /> Site Suffix: - Report <br /> Number: <br /> SWISInspection Number on the associated Survey form(Page 1) <br /> I <br /> Number: - - Photos Taken Q Yes No <br /> Prope, ,wner,. s „ <br /> Name Phone Aunber Mailing Address City State ZIP Code <br /> O PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption O Permitted Q Exempt <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® Excluded Q Unpermitted <br /> Q 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast <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 /> Q 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days (5 Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> V A WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> Q O PRC§42824-Major Waste Tire Facility Permit O (a)Signs Q (b)Site Attendant Q (c)Access <br /> O O PRC§42834-Minor Waste Tire Facility Permit <br /> Q (1)Impermeable Barrier 0 (2)Approved Vector Plan i <br /> O O PRC§42850(a)-Complies with Terms of Permit <br /> O O 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> O O 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> O O 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Q (f)Siting(New Facilities) <br /> O O 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 (h)Protection from Pyrolytic Oil Runoff <br /> MIMIC <br /> O (a)Communication Equipment Q (c)Water Supply <br /> O (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> 1"r✓ Q � � i,t_)(( � ;-- �, � 1 c tr>y � U�" '�` ,yt `�� -,�fe' ..�v �� �r ; <br /> r oyI Q S ��Q S�tj�G�I t,() � r � � ll <br /> Al`%,vrt fu or ti )b 1j, =,11 ►-� �_ o r r a 1/--e e(d 16 vit. <br /> � 1 - } — <br /> ►�I�1�L�.�-P�� r vi�'vV��� �7Y� r'� � .-(�.�•4�. 1�t-� �jl�)l�tlir`r1 � d ,�t•-�(. <br /> I 15386 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X G X A M P L It 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />