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Waste Tire vey & Inspection Rei. t SURVEY REQUIRED <br /> State of California <br /> -r - Inspection Form - Page- CIWMB 182(New 04104) - ---- ---_---- — <br /> California Integrated Waste Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details — <br /> TPID- <br /> i lJ C - Inspection a'1 .� l� I _ <br /> Site Suffix: Report I � 3 <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken Q Yes Q No <br /> Property Owner <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 O permitted O Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 4D 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 O 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 <br /> 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 00 14 CCR§17352-Site Security <br /> 0 O PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> 0 O PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> Q 0 PRC§42850(a)-Complies with Terms of Permit 00 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O Q 14 CCR§18420(a)-Applicable for Permit O (a)Storage Units <br /> O Q 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> Q O 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> O (d)Drainage <br /> 0 O 14 CCR§18433-Emergency Response Plan <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement O (f)Siting(New Facilities) <br /> O O 14 CCR§18447-Records Available O (g)Rim Removal <br /> O Q 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment O (c)Water Supply O O 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> :V:J] <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E' A Ml P I� 1 2 3 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />