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:, Waste Tire S#ey & Inspection Re* <br />State of California <br />CIWMB Waste <br />eManag) Inspection Form - Page 2 <br />California Integrated Waste Management Board <br />SURVEY REQUIRED <br />Part C - Facility Information <br />OLUE UM 6LHlir% 111r% rC11 <br />Business Profile <br />Inspection Details <br />V <br />TPID - ' (� _7,5 O t <br />Site Suffix: — I ` <br />SWIS <br />Number: <br />Inspection I _ I <br />Report I c) 5 <br />Number: <br />Inspection Number on the associated Survey form (Page 1) <br />Photos Taken 0 Yes 0 No <br />Property Owner <br />Permit Requirements <br />Exempt Business Type (Fill if applicable) <br />Permitted Regulatory Status (Fill one) <br />0 PRC § 42823.5 - Cement Manufacturing Plant with written verification that the facility qualifies for exemption <br />Q <br />O <br />O <br />O <br />O <br />O <br />O Permitted 0 Exempt <br />® Excluded 0 Unpermitted <br />Excluded Business Types (Fill if applicable) <br />0 PRC § 42808 - Permitted Solid Waste Facility (Landfill, Transfer Station) <br />O 14 CCR § 18420 (a) (2) - Agricultural < 5,000 tires incapable of holding water & used for bumpers or ballast <br />O 14 CCR § 18420 (a) (4) -Tire retreading facility with no more than 3,000 waste tires on premises <br />O 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 <br />0 (a) Signs 0 (b) Site Attendant 0 (c) Access <br />Facility Type (Fill one) <br />O Major WTF (? 5,000 Tires) <br />Minor WTF (500 - 4,999 Tires) <br />Part D - Insoection of Waste Tire Facility <br />V I <br />A I <br />-WASTE TIRE STORAGE STANDARDS <br />1, <br />,, I LI2 <br />V <br />A <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />Permit Requirements <br />001 <br />14 CCR § 17352 - Site Security <br />00 <br />O <br />O <br />O <br />O <br />O <br />O <br />Q <br />O <br />O <br />O <br />O <br />O <br />PRC § 42824 - Major Waste Tire Facility Permit <br />PRC § 42834 - Minor Waste Tire Facility Permit <br />PRC § 42850(a) - Complies with Terms of Permit <br />14 CCR § 18420(a) - Applicable for Permit <br />14 CCR § 18423 - Filing Application for Permit <br />14 CCR § 18432 - Operations Plan <br />14 CCR § 18433 - Emergency Response Plan <br />0 (a) Signs 0 (b) Site Attendant 0 (c) Access <br />00 <br />14 CCR § 17353(a) - Vector Control <br />0 (1) Impermeable Barrier 0 (2) Approved Vector Plan <br />00 <br />14 CCR § 17354 - Storage of Waste Tires Outdoors <br />0 (a) Storage Units <br />0 (b) Fire Lanes <br />0 (c) Fire District Requirements <br />0 (d) Drainage <br />0 (e) Slope/Grade <br />0 (f) Siting (New Facilities) <br />0 (g) Rim Removal <br />0 (h) Protection from Pyrolytic Oil Runoff <br />Recordkeeping Requirement <br />O <br />O <br />14 CCR § 18447 - Records Available <br />O <br />Q <br />1 14 CCR § 17351 - Fire Prevention Measures <br />0 (a) Communication Equipment 0 (c) Water Supply <br />0 (b) Fire Equipment 0 (d) Other Requirements <br />Q <br />Q <br />14 CCR § 17356 - Indoor Storage <br />L <br />Facility Compliance with NFPA 231 D-1989 <br />Comments <br />INSTRUCTIONS ON BACK <br />Correct: <br />Incorrect: <br />1, <br />,, I LI2 <br />15386 <br />White Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />