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:�. Waste Tire <br /> SulveY & Inspection Rep SURVEY REQUIRED <br /> State of California <br /> CIgrated Waite <br /> 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: / Q 5 Report 6 9 <br /> l �l <br /> Number: C l <br /> SWIS Inspection Number on the associated Survey form(Page 4) <br /> Number: - Photos Taken Q Yes Q No <br /> Property Owner <br /> (ri ll E ✓CS- �c _ <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 O Permitted Q Exempt <br /> Excluded Business Types(Fill if applicable) <br /> O PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) ® Excluded Q Unpermitted <br /> O 14 CCR§18420(a)(2)-Agricultural<5,000 tires incapable of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> O 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 /> O 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 00 14 CCR§17352-Site Security <br /> O O PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> O O PRC§42834-Minor Waste Tire Facility Permit 00 14 CCR§17353(a)-Vector Control <br /> Q (1)Impermeable Barrier O (2)Approved Vector Plan <br /> O O PRC§42850(a)-Complies with Terms of Permit O O 14 CCR§17354-Storage of Waste Tires Outdoors <br /> O O 14 CCR§18420(a)-Applicable for Permit Q (a)Storage Units <br /> O O 14 CCR§18423-Filing Application for Permit O (b)Fire Lanes <br /> O O 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> Q (d)Drainage <br /> O O 14 CCR§18433-Emergency Response Plan Q (e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> O O 14 CCR§18447-Records Available 0 (g)Rim Removal <br /> 00 14 CCR§17351-Fire Prevention Measures (h)Protection from Pyrolytic Oil Runoff <br /> Q (a)Communication Equipment _&(c)Water Supply O O 14 CCR§17356-Indoor Storage <br /> Q (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231 D-1989 <br /> Comments <br /> ee �ovn,enCPV <br /> �F�Inc ,, hh I_ �� 15386 <br /> INSTRUCTIONS ON BACK Correct: correct ( � X A ; 1 �. 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />