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Waste Tire Survey & Inspection Repurt SURVEY REQUIRED ■ <br /> M :; <br /> State of California <br /> CIWtdB 182(New 04104) <br /> Inspection Form - Page 2 -- - <br /> California Integrated Waste Management Board <br /> Part C - Facility Information - BLUE OR R BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- r 2 (_ 1� /� Inspection <br /> Site Suffix: ` 3 �U J \y 1 - V Repots <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: ' Photos Taken 0 Yes 0 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 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® 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 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 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 /> V A , WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 0 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit Q (a)Signs Q (b)Site Attendant Q (c)Access <br /> 0 0 PRC§42834-Minor Waste Tire Facility Permit 0 0 1 14 CCR§17353(a)-Vector Control <br /> Q (1)Impermeable Barrier Q (2)Approved Vector Plan <br /> 0 0 PRC§42850(a)-Complies with Terms of Permit O 0 1 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit Q (b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan Q (c)Fire District Requirements <br /> Q (d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <br /> Q (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 014 CCR§18447-Records Available Q (g)Rim Removal <br /> 0 0 14 CCR§17351-Fire Prevention Measures Q (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment Q (c)Water Supply 0 0 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment Q (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> NSONBACK Correct:* Incorrect: � , 15386J A P �INSTRUCTIO <br /> - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />