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- n `�_ Waste Tire Survey & Inspection Report <br /> - State o}C 2ifomla n� <br /> CIWMB19 (New 04104) Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> Part C-Facility Information BLUE OR BLACK INK PEN <br /> Business Profile fnepecllonl)etaits <br /> TPID- q Inspection ?? <br /> Site Suffix: <br /> SWIS Inspection Number on the associated Survey fomi(Page 1) <br /> Number: Photos Taken Q Yes Q No <br /> PropeRy Owner - - <br /> T - <br /> Exempt Business Type (Fill If applicable). <br /> � - Permitted Regulatory Status(Fill one) <br /> Q PRC§42823.5-Cement Manufacturing Plant with written verification that the facility quaif'Ies for exemption <br /> Excluded Business Types(Fill if applicable) Q Permitted Q Exempt <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q Excluded Q Unpermitted <br /> Q 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> O 14 CCR§18420(a)(4)-Tire retreading facility with no more than 3,000 waste tires on premises Q Major WTF (>_5,000 Tires) <br /> Q 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 & e -TEe dealer.storklg 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 /> Permit Requirements 14 CCR§17362-Site SseurHy <br /> © Q PRC§42824-Major Waste Tye Facility Permit 0(a)Signs 0(b)Site Attendant 0(c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit Q0 14 CCR§17353(a):Vector control ` <br /> Q Q PRC§42650(a)-Complies with Terms of Permit 0(1)Impermeable Barrier 0(2)Approved Vector Plan <br /> 00 14 CCR§17354-St_orage of Waste Tires Outdoors <br /> O O 14 CCR§18420(a)-Applicable for Permit •(a)Storage Units <br /> Q O 14 CCR§18423-Filing Application for Permit 0(b)Fire Lanes <br /> O 'Q 14 CCR§18432-Operations Plan 0(c)Fire District Requirements <br /> O Q 14 CCR§18433-Emergency Response Plan 0(d)Drainage <br /> —_ _ _ 0(e)Slope/Grade <br /> Recordikiesping Requirement <br /> - O(f)Siting(New Facilities) <br /> Q O 14 CCR.§18447-Records Available 0(g)Rim Removal <br /> 0101 14 CCIt§373&14 Fire Prevendon'Measures 0(h)Protection from Pyrolyfic Oil Runoff <br /> 0(a)Communication Equipment . 0(c)Water Supply Q Q ' 14 CCR§17356-Indoor Storage <br /> 0(b)Fire Equipment 0`(d)Other Requirements Facility Compliance with N�IFPAt+231 D-1989 ` A <br /> Canrrrart. t'�3 S4'. L,2 ug�"�. F c.ts�,.L�was ,,,tet. Dd+Pt"t�1,1M► S{�/'� .a �-fJ"G <br /> S <br /> - ,►a o��t.' aac. ��1�'�'a L�.�cw� .� t'.t:c.�s��. wi�'L i� 1 <br /> INSTRUCTIONS ON BACK 15386 <br /> � � X �1µ PLE 1 23 <br /> ■ While Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0526305.040r <br />