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=�a„ Waste Tire S Rve & Inspection Re <br /> 1 Stale of California Y pecon p SURVEY REQUIRED <br /> CIWMB grated 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- Q Inspection <br /> Site Suffix: ,Z -I g 3 ,S - U ' Report I /t _ / C,� b 4 - C/ <br /> Number: I <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken 0 Yes 0 No <br /> I <br /> Property Owner <br /> -GK /V Rea 39a7 C&A" DrCA tSZos' <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 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 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 _ 0 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 /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant Q (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 0 01 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 /> 0 0 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 0 (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> 0 0 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> Q (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> -6- 0 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply 0 0 14 CCR§17356-Indoor Storage <br /> O(b)Fire Equipment Q (d) Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> iHa&z6 einms 6- aree, s of c6»&INSTRUCTIONS ON BACK JE!XJA'MJP1LJEJ 1112 3 15386 <br /> White Copy:CIWMB Yelfow Copy:Operator Pink Copy:LEA <br />