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APPLICATION FORM CIWMB 500(Rev. 10/02) Page 2 of 2 VI. EQUIPMENT _ Types of On-Site x Stationary Shredder ❑ Bailer x Splitter x Cutter Processing Equipment: ❑ Mobile Shredder ❑ Other: VII. PROPOSED CHANGE TO FACILITY ❑ Design(descrihe): Use of existing structure and paved parcel for the manufacture of Tire Derived Aggregate, ❑ Operation(describe): ❑ Administrative(describe): x No Change. Proposed Date of Change: Proposed operational date of April 1,2010 VIII. REQUIRED DOCUMENTS(attachments) x Operation Plan x Environmental Form x Emergency Response Plan (CIWMB 501) (CIW%IB 502) (CIWMB 503) Major&Minor WTF: x Vector Control Info. x Fire Department Info. Property Lease Agreement x Verification that applicable local,state,and federal permits and approvals have been acquired. For Major WTFs,also x Closuureo4Plan ❑ Reduction/Elimination Plan x Financial Assurance include the following: x Operating Liability IX. OWNER SIGNATURE 1 cert i,that this document and all attachments were prepared under my direction at-supervision. I have inquired gl'the person or persons who manage the system or those persons direct41-responsible for gathering the information, and certify that the information submitted is, to the hast of my knowledge and belief;true, accurate and complete. Property Owner or Agent Signature: Typed Name& Title: Mark W. Hope,P resident Date: 102/.-;'V/0 X. OPERATOR CERTIFICATION I certify that this document and all attachments were prepared under my direction or supervision. I have inquired of the person or persons who manage the system or those persons directly responsible for gathering the information, and certifv that the inforntalion submitted is, to the best of my knowledge and belief, true, accurate and complete. Facility Operator or Agent Signature: '' Typed Name&Title: Mark W. Hope. President Date: 3 oyO�v