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- i <br /> Waste Tire vey & Inspection Refit SURVEY REQUIRED <br /> ■ �. State of California ■ <br /> Iy± p <br /> CIWMB Waste <br /> eManag) Inspection Form - Page 2 <br /> California Integrated Waste Management Board - <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- rr )) (� J Q / Inspection <br /> Site Suffix: f �^ q�� ( tJ - Q f Report <br /> Number: I - I 101113101 r� O { <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: FTT I I Photos Taken 0 Yes 0 No <br /> Pro erty Owner <br /> ?q3 �. l�rrL Lodi <br /> Name 'Phone Number Mailing Address J City State ZIP Code <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) 0 Excluded Q5 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 (b 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 /> 0 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 J_A WASTE TIRE STORAGE STANDARDS V i A <br /> Permit Requirements 0 14 CCR§17352-Site Security <br /> 0 PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant 0 (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 14 CCR§17353(a)-Vector Control <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit 0 (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit 0 (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> 101 0 1 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkee ing Requirement <br /> 0 (f)Siting(New.Facilities) <br /> 0 0 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 14 CCR§17351-Fire Prevention Measures 0 (h)Protection from Pyrolytic Oil Runoff <br /> i <br /> 0 (a)Communication Equipment 0 (c)Water Supply 10 0 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d)Other Requirements ' Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> CiNiveoperlTt1T IeGL r T I I n Y"f - {- -f 11 1S <br /> bu F1 -F Tile,lAyn ao Tf f-or S-foe, Aill Jrad-ers twfs <br /> OL 6U. WgYPr� — f oc n . r ray eY e f s <br /> wQ r e I�o�l�o( o b srir� a� r wa S�e5 . fir 7rcr s <br /> WWf— iouVAli.h= ed a Aa110vis a <br /> 1 e V/ov* Descry 1aov1 e T e { <br /> J_TV S 7cpg ZAT' L 1099 A 5'7r� Sq � 7/I,ITTI'Ittttn)•1 1,4( <br /> . <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: :X� E A�1A P J.l- E 0 2 3 15386 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />