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Waste Tire S y & Inspection Rer _t SURVEY REQUIRED <br /> '::.r.- State of California e <br /> CIgrated aiteMana a 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 /> Site - ' I O © ` - Q 1 Inspection - 2- q 9 71 <br /> Site Suffix: <br /> b Report I ` <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 /> 0 PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption • Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) O 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 /> 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 storing no more than 1,500 waste tires for 90 days Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> V1 A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> O O PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> O PRC§42850(a)-Complies with Terms of Permit Q (1) Impermeable Barrier O (2)Approved Vector Plan <br /> 00 Q 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q O 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> 0 O 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> O Q 14 CCR§18433-Emergency Response Plan O (d)Drainage <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> Q O 14 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 Q 1 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q Water Supply 00 14 CCR§17356-Indoor Storage <br /> %Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments le, <br /> ,� <br /> �(1 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �V) I J.E ,� PLE1 11, 12 3 15386 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />