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�' ■ " Waste Tire Wey & Inspection Re t <br /> IN�� --.. SURVEY REQUIRED <br /> teAuz:r State of California <br /> CIWMB182(Ne wm04104) Inspection Form - Page 2 <br /> California Integrated Waste Manageent Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> - _ Inspection <br /> Site <br /> Site Suffix: Report <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: EEI - ELI I t I T] Photos Taken 0 Yes Q No <br /> Property Owner <br /> 9o(H(3r �1 `rl5f S <br /> Name_) J Phone Number Mailing Address City State ZIP Code <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> o 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) i ((�9- Excluded Q 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 /> 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises O 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§118420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days O Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> V A 1 WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements ^r 14 CCR§17352-Site Security <br /> O O PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> O O PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> 0 (1) Impermeable Barrier 0 (2)Approved Vector Plan <br /> 10 O PRC§42850(a)-Complies with Terms of Permit F 07 17 <br /> 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O Q 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> 0 Q 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 />� P <br /> 01 <br /> O 14 CCR§18433-Emergency Response Plan 0(d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> o Q 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 14 CCR§17351 -Fire Prevention Measures <br /> 0 (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 (c)Water Supply 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> 111 1.,fP'j-iviri rP ,iy ir H axA(eit' 61d -Nsc rci6 7(o u­ k. <br /> _� k�yi> of J fyr --fel`. t{ it1 r_ r. Oofie( 7 -'1))5l./ uoo� <br /> -I d2k,e s OK'd t&V M CHJDYE DYE CTS (,Cf ed' WP� ��- 0 <br /> Tz— <br /> • <br /> � r <br /> r�s as I-�ecfed, rye 0 Q�ier+ld om aa���ts1�Vt` L SL's r,1 -tiAl( <br /> (-, h-PX+ 1&*ed1,1,y7 . ak] NO) 1,001, A 151_ L5 d /NOfE WGiIle (,je'j k"',I/illof�,- <br /> T6,p,�n �4 yvi s we i�,i A)e ftq and Qct -b St.,le-- af1-.e,- 4 tm I -. <br /> rD r dfioa � 0 i X Jo '(stilt _2X&- The 0 hill ry)b-I D a(m for /;J: <br /> l � 15386 <br /> INSTRUCTIONS ON BACK. Correct: Incorrect: c Vii( ,A P ( P 1 <br /> ■ White Copy:CIWMB• Yellow Copy:Operator Pink Copy:LEA ® ■ <br />