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'SURVEY REQUIRED <br /> Waste The Sey & Inspection Ret ' ■ <br /> W? State of California <br /> --U, COMB Integrated <br /> Waste <br /> eManag) Inspection Form - Page 2 <br /> California Integrated Waste Management Board <br /> Part C - Facility Information <br /> BLUE OR BLACK INK PEN <br /> MEMEL <br /> TPID- Inspection <br /> Site Suffix: - Report < < <br /> Number. -- <br /> SWIS mInspection Number on the associated Survey form(Page 1) <br /> Number: <br /> Photos Taken�I m ®Yes 0 No <br /> Property Owner <br /> r <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 0 Exempt <br /> Excluded Business Types(Fill if applicable) . w . <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 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> 0 14 CCR§18420(a)(7)&(e)-Tire dealer storing no more than 1,500 waste tires for 90 days 0 Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> �V A ' WASTE TIRE STORAGE STANDARDS V A <br /> Sire.,CC.I', <br /> 0 0 R17352_-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a) Signs O (b)Site Attendant O (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit C) 0 14 CCR§,17353(a).Vector Control <br /> O (1) Impermeable Barrier O (2)Approved Vector Plan <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit , <br /> 0 0 14 CCR§ a7354-Storage of Vt/rite Tires Outdoor) <br /> 0 0 14 CCR§18420(a)-Applicable for Permit O (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> O (c) Fire District Requirements <br /> 0 0 14 CCR§18432-Operations Plan <br /> O (d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <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 O (c)Water Supply 0 0 14 GCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments t/•t //�� 11 ��Tr 4 1/Jy7L /J ✓ / f/ <br /> d 4)1 i ( �) (tt l U r,'k + <br /> �of . se7r't�1 1�� ►� v�CP��c rr►C,rr� ��IP� n hy � in t,UCt le1,. <br /> + J76t('t1i`4U mujyo �4 <br /> V1 O f C' ryt c:t I vi a T kf a _.. <br /> NOV CAVICt 0d�p) OV, 110C11 (J5 anJ aPIP iI'CQI iovIVIG <br /> fr Wj 4h i�t�t�Pt rc�n �Qr�c�r- C0Py' <br /> j <br /> !Dy) b1J s 6(C q r 1,�t f 1 r t'i /✓ ! d <br /> C <br /> � : <br /> _._ ..; _.... 15386 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect 'V , " P I� T <br /> _� <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />