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Waste TireBu rvey & Inspection 41port <br /> i0:7t: State of California <br /> CIgrated Waste <br /> eManagy 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: ; O , Report <br /> Number: <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) Ex IQ,ed. 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 /> p 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 CCR§18420(a)(6)-Auto dismantler storing no more than 1,500 waste tires for less than 90 days <br /> O 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 /> Permit Requirements Q Q 14 CCR§17352 Site Security <br /> Q Q PRC§42824-Major Waste Tire Facility Permit (a)Signs (b)Site Attendant O (c)Access <br /> Q Q PRC§42834-Minor Waste Tire Facility Permit Q Q _14 CCR§17353(a)-Vector Control__ <br /> PRC§42850(a)-Complies with Terms of Permit 0 (1) Impermeable Barrier O (2)Approved Vector Plan <br /> 0 Q ® 14 CCR§17354-Storage of Waste Tires Outdoors <br /> Q Q 14 CCR§18420(a)-Applicable for Permit ® (a)Storage Units <br /> Q Q 14 CCR§18423-Filing Application for Permit O (b) Fire Lanes <br /> Q Q 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> 0 (d)Drainage <br /> Q Q 14 CCR§18433-Emergency Response Plan i <br /> O (e)Slope/Grade <br /> Recordkeeping Requirement__ p (f)Siting(New Facilities) <br /> Q Q 14 CCR§18447-Records Available O (g) Rim Removal <br /> 00- 14 CCR§17351 -Fire Prevention Measures O (h) Protection from Pyrolytic Oil Runoff <br /> 0 (a)Communication Equipment Q (c)Water Suppfy 00 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment O (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> �tL C ,z 11_1; <br /> W LA. <br /> V � u <br /> LA <br /> INSTRUCTIONS ON BAACopy:71r��WM" <br /> ec _ Incarreat ,'1 IEX A p EI f 2 3 15386 <br /> �vWYellow Copy:Operator Pink Copy:LEA <br />