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.S <br /> Waste Tire Su trey & Inspection Rep ISURVEY REQUIRED <br /> Slate of California ' <br /> CalifornialntCIWMB egratedfWastteManagelInspection Form - Page 2 <br /> Management <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile <br /> V0 f)A2-6_ Inspection Details <br /> —ls <br /> TPID- Inspection <br /> Report <br /> 01 <br /> '7 <br /> Site Suffix: / I ✓ I L Number; <br /> ; Inspection Number,on the <br /> _ associated Survey <br /> —fo�rmI C�-(Pi <br /> ag`e 41) <br /> SW1S _ <br /> I <br /> Number: _ Photos Taken ®Yes 0 No <br /> Property Owner <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> 0 PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption 0 permitted Q 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 for bumpers or ballast Facility 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 CC R§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> 0 Minor WTF (500-4,999 Tires) <br /> LO_14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days <br /> Part D- Inspection of Waste Tire Facility 6,1 <br /> VI A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements ® 0 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit ®(a)Signs 0 (b)Site Attendant (c)Access <br /> ® 0 PRC§42834-Minor Waste Tire Facility Permit ® 0 14 CCR§17353(a)-Vector Control <br /> Q (1)Impermeable Barrier Q (2)Approved Vector Plan <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit ® 0 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit ® (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> ® (d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> ® 0 14 CCR§17351 -Fire Prevention Measures' 0 (h)Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment O (c)Water Supply 0 , 0 14 CCR§17356-Indoor Storage <br /> Q (b)f=ire Equipment O (d)Other Requirements Facility Compliancewith NFPA 231D-1989 <br /> Comments.f ai rne. A 11A.fr2� uja It/ Q +� C� �� ZZ <br /> 'DYtS �'jt 11/���' <br /> �" �� �+i f• <br /> j a✓ 011 D W- � r►'I,P Q i L C e _ cert SP- ' 5r r a I a 6 <br /> aw) cvi)1� DI!iw- Q�Aj 04 r' <br /> V;ola,fi0� f r,SSue s -td <br /> Waftt' C(0eAW Je,_q_oh cf,_ Lot f arJ-ae hofed <br /> � <br /> INSTRUCTIONS ON BACK Correct: incorrect: R EIX A hh 'P L � .� 12 3 15386 <br /> White Copy.CIWM8 Yellow Copy:Operator fink Copy.LEA <br />