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Waste Tire 6,. vey & Inspection Re t SURVEY REQUIRED <br /> -' State of California <br /> CIWMa1W (New 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- �4J � Ql Inspection <br /> Site Suffix: Report <br /> J <br /> Number: <br /> SWIS Inspection Number on the associated Survey form(Page 1) <br /> Number: Photos Taken 0 Yes 0 No <br /> Property Owner <br /> Exempt Business Type (Fill if applicable) Permitted Regulatory Status (Fill one) <br /> 0 PRC§42823.5-Cement Manufacturing Plant With written verification that the facility qualifies for exemption 0 Permitted 0 Exempt <br /> Excluded Business Types(Fill if applicable) <br /> 0 PRC§42808-Permitted Solid Waste Facility(Landfill,Transfer Station) 0 Excluded 0 Unpermitted <br /> 0 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 0 Major WTF (>_5,000 Tires) <br /> 0 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 fires for 90 da ® Minor WTF (500-4,999 Tires) <br /> Part D- Inspection of Waste Tire Facility <br /> V I A I WASTE TIRE STORAGE STANDARDS V A <br /> Permit Requirements 00 14 CCR§17352-Site Security <br /> 0 0 PRC§42824-Major Waste Tire Facility Permit O (a)Signs O (b)Site Attendant O (c)Access <br /> 0 0 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 /> 0 0 PRC§42850(a)-Complies with Terms of Permit 90 14 CCR§17354-Storage of Waste Tires Outdoors <br /> 0 0 14 CCR§18420(a)-Applicable for Permit S(a)Storage Units <br /> 0 0 14 CCR§18423-Filing Application for Permit O(b)Fire Lanes <br /> 0 0 14 CCR§18432-Operations Plan O (c)Fire District Requirements <br /> 0(d)Drainage <br /> 0 0 14 CCR§18433-Emergency Response Plan <br /> 0(e)Slope/Grade <br /> Recordkeeping Requirement Q (f)Siting(New Facilities) <br /> 0 0 14 CCR§18447-Records Available 0(g)Rim Removal <br /> 0 0 1 14 CCR§17351-Fire Prevention Measures O (h)Protection from Pyrolytic Oil Runoff <br /> O (a)Communication Equipment 0 (c)Water Supply 0 0 1 14 CCR§17356-Indoor Storage <br /> O (b)Fire Equipment 0 (d)Other Requirements Facility Compliance with NFPA 231D-1989 <br /> Comments <br /> I 5386 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: (� d IE XA MIP[LIEI T 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />