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.:Rl, Waste Tire *rvey & Inspection Re rt - <br /> State of California SURVEY REQUIRED ■ <br /> Inspection Form - Page 2 <br /> CIWMB 182(New 04/04) - ' ------ - -- - <br /> California Integrated Waste Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> IN li!,i lips <br /> I�FD- -- Inspection <br /> Site Suffix: U (q3] <br /> - V Report <br /> _ Number: <br /> SWIS n Inspection Number on the associated Survey (Page 1) <br /> Number: - �� - Photos Taken 0 Yes ® No <br /> MORE <br /> Property Owner.,,,, <br /> V'.o L0h IyDz D,.��uery L n CA `1 EJL/ <br /> Phone Number Mailing Address City J--TState ZIP Code <br /> Mir Exempt Business Type (Fill if applicable) �tmI teclla'' StatUs7(FllI bne� <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-�r bumpers or ballast Faciiity"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 Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> V A WASTE TIRE STORAGE STANDARDS V A <br /> '9 ,..4.r�. � r3,72 ZS@tc M3,, <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit LL O (a)Signs O (b) Site Attendant O (c,)Access <br /> 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> 010 PRC§42850(a)-Complies with Terms of Permit 4 O (1) Impermeable Barrier O (2)Approved Vector Plan <br /> I 0 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit <br /> 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 /> O (e)Slope/Grade <br /> Recordkeeping Requirement <br /> 0 (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 0 14 CCR§17351, -Fine Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment Q (c)Water Supply 00 14 CCR§17356_Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> YAM\T1ZCl � iA.)E:Y- C-ai/alAo.bly <br /> P_ Tor I0u)NnCli' 1 <br /> -� T oYl _(C <br /> g1J1QS1 <br /> _F0_Cd1TJ - Vzz �-Pz_r_(_��l_n T <br /> _�Sl� U_-1toLO) iJCAS <br /> C�1a P`(P_ �e_ 1YQ �1G �`11-� yehl.r,_ICS : <br /> T� Veh . 1_I(_ # pecnt �r <br /> Papel +,r uc-k 6 P 8--19 9 Ggi- 00z 1h <br /> 1-1-O n ra\Cl-.,1'�l 76`f I O`-I9 49 <br /> NO vN,olAkI rOs or ec,r eas G� C-6nCero noted <br /> INSTRUCTIONS ON BACK Correct:i Incorrect: A P 111215386 <br /> __..._. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />