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r <br /> Waste Tire Srey & Inspection Ret SURVEY REQUIRED <br /> _ State of California �+ ■ <br /> �= CIWMB Waste <br /> eManag) Inspection Form - Page 2 <br /> California Integrated Waste Management Board p <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: ? i I Q i 5 8 9 Report I - 1 I O � i -7 O { <br /> Number: ! f <br /> SWIS []— I Inspection Number on the associated Survey form(Page 1) <br /> Number: m - - Photos Taken Q Yes (DNo <br /> Property Owner <br /> VJitJ-,0+ C-TS _ 5fr)cLJ o.A I LfOy5 N . Wilcox 1�dI CArickion , CA <br /> Name Phone Number Mailing Address City State ZIP Code <br /> Exempt Business Type (Fill if applicable) . Permitted Regulatory Status (Fill on <br /> Q PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption <br /> Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> O PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) CD 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 /> Q 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 /> 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 V I A _ <br /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> O C) PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> Q Q I PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> 0 (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> Q PRC§42850(a) Complies with Terms of Permit <br /> i 1 1) 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 O 14 CCR§18420(a)-Applicable for Permit f 0 (a)Storage Units <br /> 0 O 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> 1 Q 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 /> Recordlikeeping Re uirement 0 (f)Siting(New Facilities) <br /> Q O 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 0 0 14 CCR§17351-Fire Prevention Measures 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 /> 1 <br /> 7 a Z) -TUC 1�1 1- Y-e_C P_IV 4_S }1 r•E S�r G m C U St o <br /> M 17'6 U) 9ss C--Ts- Trcl r-A (7 P i S'JD'�� `�`�� or l- I 1a 0 <br /> GTS _ (T C-1 4�2�0 —o �c►x�r � Gd,nc�l )GSe—;t f�— <br /> sre �- Y'r)a�ec�l bQ1 0 I d.r)- ?�,d u ctLQ,,r_ �c_I�J��e �Z Y trek <br /> C`r\-- ry-)CAVI Se sht, Or b 041 1UIC) � v, er_►������s—have—b�zx-1— <br /> N0yvo\cy�iors or OYTsas �� Cr,y)cQr,0 cored . <br /> INSTRUCTIONS ON BACK I Incorrect: ( } Exp, A'JM P 1_ E 1112 15386 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br /> I <br />