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;; - <br /> M-71 <br /> Waste Tiresuey & Inspection RepoSURVEY RE uIREState of California Q D Ins ection Form - Pa e 2 <br /> CIWMB 182(New 04/04) h �y <br /> California Integrated Waste Management Board y <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site <br /> Site Suffix: � C) Report t-3 <br /> � � � } <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: m m Photos Taken @ Yes Q No <br /> Property Owner <br /> Name Phone Number Mailing Address City State ZIP Code <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> PRC 42823.5-Cement Manufacturing Plant with written verification that the facility Q § q y 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) <br /> Excluded Q 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 facilitywith 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 WASTE TIRE STORAGE STANDARDS j V A <br /> ^Permit Requirements 014 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O (a)Signs Q (b)Site Attendant Q (c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a) Complies with Terms of Permit O (1)Impermeable Barrier ® (2)Approved Vector Plan i <br /> 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit <br /> (b)(a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> Q Q 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> (e)Slope/Grade <br /> RecordkeepLng Requirement <br /> Q (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment Q (c)Water Supply 0 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment Q (d)Other Requirements I Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> 04 <br /> tax{-_--1--:� -A,- ..©nr_..,�� !r <br /> S2" f'r 7 C7.- , -- 2/--> i <br /> l�J h IE <br /> C <br /> INSTRUCTIONS ON BACK Correct: Incorrect: I ) 15386 <br /> i"r,"( p Y <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />