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' r Waste Tore S,. vey & Inspection Rep— t SURVEY REQUIRED <br /> Stale of California �y�+ /o <br /> CIWMedW (New04/04) Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> Part C - Facilit Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: I , t , Report I I - ' 2. 55 Q <br /> Number: U <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) `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 0 Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> V I A I WASTE TIRE STORAGE STANDARDS V A <br /> -- <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a)Signs 0 (b)Site Attendant - Q (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit O (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> 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 O(d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> O(f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 0 * 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment 0(c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> O(b)Fire Equipment 0(d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (m XJA*PJLJE1 1112 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />