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Waste Tire Se ey & Inspection Rep SURVEY REQUIRED 'I <br /> State of California <br /> WS;g COMB 182(New 04104) Inspection Form page 2 <br /> California Integrated Waste Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Inspection Details <br /> Business Profile p <br /> TPID- Inspection <br /> Site Suffix: ' ;Z4a Z! (`/0 Report 7 .7 <br /> SWIs Number: Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken Q Yes ® No <br /> Property Owner <br /> �vt.�Grv►-� �i,,�u� Cz:x+��r�s�3�� S� S�- � � CA �t r <br /> I ;r� <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> Q PRC§42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 4)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 /> ® 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 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 storingno 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 I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements Q Q 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0(b)Site Attendant 0 (c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> 0(1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> Q Q PRC§42850(a)-Complies with Terms of Permit 001 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit 0(a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit 0(b)Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan 0 (c)Fire District Requirements <br /> 0 (d)Drainage <br /> Q Q 14 CCR§18433-Emergency Response Plan 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> Q Q 14 CCR§17351-Fire Prevention Measures 0 (h)Protection from Pyrolytic 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 NFPA 231D-1989 <br /> Comments <br /> - --- ---- — 15386 <br /> INSTRUCTIONS <br /> INSTRUCTIONS ON BACK Co ct: Incorrect: ��! V) ? A tM P 1. 3 <br /> ■ White Copy:C Yellow Copy:Operator Pink Copy:LEA <br />