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_ Wasteof s Tire S._ /ey & Inspection Rea t suRVEY REQUIRED ' <br /> CIWMB182(Ne wm04104) Inspection Form - Page 2 ------_-- <br /> California Integrated Waste Manageent Board <br /> Part C- Facility Information _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I ' 1 O _ I Inspection <br /> Site S _ <br /> Site Suffix: L� Report I <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: - Photos Taken Q Yes ® 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 Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ®Excluded Q Unpermitted <br /> ® 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> Q 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 ®Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> V I A WASTE TIRE STORAGE STANDARDS V A _ <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q O PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Site Attendant Q (c)Access <br /> 0 O PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector.Control <br /> Q (1)Impermeable Barrier O (2)Approved Vector Plan <br /> PRC§42850(a)-Complies with Terms of Permit 00 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 O 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q O 14 CCR§18423-Filing Application for Permit Q (b)Fire Lanes <br /> 0 O 14 CCR§18432-Operations Plan Q (c)Fire District Requirements <br /> Q (d)Drainage <br /> 0 O 14 CCR§18433-Emergency Response Plan <br /> Q (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 O 14 CCR§18447-Records Available Q (g)Rim Removal <br /> Q O 14 CCR§17351-Fire Prevention Measures Q (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply O O 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />