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'State okalifornia California Integrated Waste <br /> CIWMB 500(Rev. 10/02) Management Board <br /> WASTE TIRE FACILITY <br /> PERMIT APPLICATION <br /> I. TYPE OF APPLICATION (please print or type) SWIS#: <br /> ❑ New ❑ Permit Permit CIWMB use onl <br /> Permit Renewal ❑ Revision Date Received: <br /> Application Date Acce ted: <br /> ❑ Amendment Date Rejected: <br /> II. TYPE OF FACILITY <br /> ❑ Existing ❑ Proposed <br /> ❑ Major Waste Tire Facility(5,000 or more tires) <br /> ❑ Minor Waste Tire Facility(500 or more tires,but less than 5,000) <br /> III. GENERAL INFORMATION <br /> Facility Name: <br /> Facility Mailing Address: <br /> City; I I County: State: Zip: Phone: <br /> Facility Location(if different from mailing address): <br /> City; County: State: Zip: Phone: <br /> Assessor's Parcel Number(s): GPS Coordinates: Site Acreage: <br /> Facility Operator's Name: <br /> Mailing Address: <br /> City; I I County: State: Zip: Phone: <br /> Property Owner's Name(if different from operator): <br /> Mailing Address: <br /> City; I I County: State: Zip: Phone: <br /> IV. AGENCY INFORMATION <br /> Fire Authority Agency Name: <br /> Contact Person: Phone: <br /> Vector Control/Mosquito Abatement Agency Name: <br /> Contact Person: I <br /> Phone: <br /> V. TYPE AND QUANTITY OF WASTE TIRES <br /> ❑ Whole Passenger ❑ Whole Truck ❑ Whole Tractor ❑ Split Tires <br /> Type of Waste ❑ <br /> Tires Received: Whole Earthmover/Construction Equipment F1 Cut Tires Shredded Tires <br /> ❑ Other: <br /> Number of Waste Tires Stored or Maintained On-Site: <br /> Maximum Capacity: <br />