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Waste Tire ECey & Inspection ReArt <br /> State of California <br /> CIWMedWaitMew anage Inspection Form - Page 2 <br /> California Integrated Weate Management Board <br /> Part C - Facility Information BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> Site Suffix: 1 ` U t Report <br /> Number: (J D V 1 <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 /> ® PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® 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 /> 0 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 CC R§ 18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> Q 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 /> .:.v. •v- , ; '� mai''l%'.�3%T•':Si7.•..r✓!4i:a.`i_.%p,^.^�„'/: ;^�S? T'i74t:=>:'.a <br /> i�;�.;�.. ../ / i, %T' '!? %fiJ/�-/.<'-;•r,•��„ fid%`. �?%�,.i..T'i,/i <br /> /i <br /> .i <br /> Permit Requirements Q Q 14 CCR§17352-Site Security _ <br /> 05_FPRG <br /> §42824-Major Waste Tire Facility Permit _ Q (a)Signs O (b)Site Attendant O (c)Access <br /> Q PRC§42834-Minor Waste Tire Facility Permit Q Q 14 CCR§17353(a)-Vector Control — 1 <br /> Q Q PRC§42850(a)-Complies with Terms of Permit _ O (1)Impermeable Barrier O (2)Approved Vector Plan I+ <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 /> 0, Q 14 CCR§18423-Filing Application for Permit + O (b)Fire Lanes <br /> Q I Q 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q+ Q 14 CCR§ 18433-Emergency Response Plan O (d)Drainage <br /> l O(e)Slope/Grade <br /> Recordkeeping Requirement p (t)Siting(New Facilities) <br /> Q '® 14 CCR§18447-Records Available O (g)Rim Removal <br /> Q Q 14 CCR§17351 -Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment O (c)Water Supply Q 14 CCR§.17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1 989 <br /> Comments <br /> INSTRUCTIONS ON BACK Cd i'i6) ± �t +l ir' ft>XY , A M P L I� 3 j 2 15386 <br /> nIEX <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />