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;, Waste Tire Avey & Inspection Rep SURVEY REQUIRED <br /> "i". State of California <br /> CIWMBI82(New04104) <br /> nage 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: , l l Report I /, G� [" S q 3 <br /> Number: 1 V �J <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 /> 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) 0 Excluded ® 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 0 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 Q Q 14 CCR§17352-Site Security <br /> 0 Q PRC§42824-Major Waste Tire Facility Permit 0 (a)Signs 0 (b)Site Attendant O (c)Access <br /> Q ® PRC§42834-Minor Waste Tire Facility Permit 0 0 14 CCR§17353(a)-Vector Control <br /> Q (1)Impermeable Barrier 0 (2)Approved Vector Plan <br /> Q Q PRC§42850(a)-Complies with Terms of Permit O 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 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q (d)Drainage <br /> Q Q 14 CCR§18433-Emergency Response Plan <br /> 0 (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> Q 0 14 CCR§18447-Records Available Q (g)Rim Removal <br /> O Q 1 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> • (a)Communication Equipment Q (c)Water Supply O 0 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments se <br /> 7 <br /> • 15386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � !s: A h�� �' l_ E11112!]3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />