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Waste Tire ",Arvey & Inspection R,.port SURVEY REQUIRED <br /> State of California <br /> CIWM 6192(New 04104) Inspection Form - Page 2 -_ - ----- ----------- --------- -- -- <br /> r. 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: <br /> Report I — ` p J C) a <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken Q Yes No <br /> Property Owner <br /> Exempt Business Type (Fill if applicacle) _ Permitted Regulatory Status (Fill one) <br /> O PRC §42823.5-Cement Manufacturing-art with written •=rification that the facility qualifies for exemption Q permitted 0 Exempt <br /> Excluded Business Types(Fill if applicablei <br /> O PRC§42808-Permitted Solid Waste Fac -r(Landfill.Tra-sfer Station) ® Excluded 0 Unpermitted <br /> O 14 CCR§ 18420(a)(2)-Agricultural<5 . tires incapac e of holding water&used for bumpers or ballast Facility Type(Fill one) <br /> O 14 CCR§ 18420(a)(4)-Tire retreading'a. ,tywith no i-than 3,000 waste tires on premises O Major WTF (>-5,000 Tires) <br /> O 14 CCR§ 18420(a)(6)-Auto dismantler s-cnng no more_-an 1,500 waste tires for less than 90 days <br /> Q Minor WTF (500-4,999 Tires) <br /> ® 14 CCR§ 18420(a)(7)&(e)-Tire dealer s-:r!ng no more:-an 1,500 waste tires for 90 days — <br /> Part D - Inspection of Waste Tire Facility <br /> V A ' WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 0 O 14 CCR§17352-Site Security <br /> O O PRC§42224-Major Waste Tire F a, ity Permit 0 (a) Signs 0 (b) Site Attendant 0 (c)Access <br /> O O PRC§42834-Minor Waste Tire F».lity Permit I O O 14 CCR§17353(a)-Vector Control <br /> 0 (1) Impermeable Barrier 0 (2)Approved Vector Plan- <br /> o 0 <br /> PRC§42850(a)-Complies with Ty--ns of Permit <br /> 0 Q _-14 CCR§17354-Storage of Waste Tires Outdoors <br /> O O 14 CCR§18420(a)-Applicable for Permit 0 (a)Storage Units <br /> O O 14 CCR§18423-Filing Applicaticr•for Permit 0 (b) Fire Lanes <br /> Q O 14 CCR§18432-Operations Plan 0 (c) Fire District Requirements <br /> 0 (d)Drainage <br /> O O 14 CCR§18433-Emergency Response Plan 0 (e)Slope/Grade <br /> Recordkeeping Requirement 0 (f)Siting(New Facilities) <br /> Q O 14 CCR§ 18447-Records Availacie 0 (g) Rim Removal <br /> O O 14 CCR§17351 -Fire Prevention Measures (h) Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment 0 i `Nater Supply O O 14 CCR§17356-Indoor Storage <br /> 0 (b)Fire Equipment 0 (d.Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments Z.°l S' •� wit o1�.ti?i •,`, `� �t �n a <br /> ��f&=!a i:5'[-��C.c,d ``�,�ou.i,l t v(� l C>.r w��Tr1tc <br /> � 000�'4��t� <br /> I <br /> -- -- - - -- --- --- --- -- --- - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X A MIP LIE 1 2 3 15386 <br /> �allaN Copy Operator Pink Copy.LEA <br />