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FORM NO.M-105548-CI WMB M12 5004 37654321 <br /> ne <br /> Waste Tire Survey & Inspection Report <br /> State of California <br /> CIWMB182(New <br /> 04/04) 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: \ fj 8 3 (a Cr l Report I _ ` C> <br /> Number: b h J <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken Q Yes Q No <br /> Property Owner -- — - - --- -- - <br /> �*a�rhr� V - <br /> �� (T1 6< (.4sw-,�oC-(� �Z (:cv. CA 5 2,3 <br /> - r <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> Q PRC §42823.5-Cement Manufacturing Plant with written verification that the facility qualifies for exemption Q Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> Q PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) Q 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 Q 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 Q Minor WTF (500-4,999 Tires) <br /> Part D - Inspection of Waste Tire Facility <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit O (a)Signs Q (b)Site Attendant Q (c)Access <br /> 1 Q PRC§42834-Minor Waste Tire Facility Permit Q Q 14 CCR§17353(a)-Vector Control <br /> Q Q PRC§42850(a)-Complies with Terms of Permit 0 (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> Q Q 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 0 (c)Fire District Requirements <br /> Q Q 14 CCR§18433-Emergency Response Plan 0 (d)Drainage <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement <br /> Q (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available Q (g)Rim Removal <br /> Q O 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 /> O (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> �Lnle�' A,C-25 6 A�—_ A vo C <br /> ` <br /> TU ^� Ct.,5.c— <br /> - <br /> - INSTRUCTIONS ON BACK > P L l 3 15386 <br />