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Waste Tire S' vey & Inspection Re* <br /> �. .n, StatMB e of California - SURVEY-REQUIRED <br /> �; CI Integrated <br /> stew04/04) <br /> anage Inspection Form Page 2 <br /> California Integrated Waste Management Board <br /> Part C- Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: 6 / Z— l Report I - / U 7 / <br /> Number: / <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken ® Yes Q No <br /> Property Owner A - - <br /> J",5r <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 Q Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q Excluded 4W 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 Q 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 /> 14 CCR 18420 a 7 & e -Tire dealer storm no 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 i A WASTE TIRE_STORAGE STANDARDS V A <br /> - - <br /> Permit Requirements 0 . 0 14 CCR§17352-Site Security <br /> ® Q PRC§42824-Major Waste Tire Facility Permit O (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 /> Q Q PRC§42850(a)-Complies with Terms of Permit O (1)Impermeable Barrier O (2)Approved Vector Plan <br /> 00 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q Q 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 0 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q(a)Communication Equipment Q (c)Water Supply 00 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> OFF 0: <br /> - ` 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect A ,,hk. P L E! 111 ? 3 <br /> _ <br /> E <br /> White Copy:CIWMB Yellow <br /> Copy:Operator Pink Copy:LEA <br />