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r APPL.T(,ATION FORM CIWMB 500 (Rev. 10/02) <br /> Page 2 of 2 <br /> VI. EQUIPMENT <br /> Types of On-Site ❑ Stationary Shredder ❑ Bailer ❑ Splitter ❑ Cutter <br /> Processing Equipment: ❑ Mobile Shredder ❑ Other: <br /> VII. PROPOSED CHANGE TO FACILITY <br /> ❑ Design(describe): <br /> ❑ Operation(describe): <br /> F-1Administrative(describe): <br /> ❑ No Change: <br /> Proposed Date of Change: <br /> VIII. REQUIRED DOCUMENTS(attachments) <br /> ❑ Operation Plan ❑ Environmental Form ❑ Emergency Response Plan <br /> CIWMB 501 CIWMB 502 (CIWMB 503 <br /> Major&Minor WTF: ❑ Vector Control Info. ❑ Fire Departmeni Info. ❑ Property Lease Agreement <br /> ❑ Verification that applicable local, state,and federal permits and approvals have been acquired. <br /> Closure Plan ❑ Reduction/Elimination Plan ❑ Financial Assurance <br /> For Major WTFs,also ❑ CIWMB 5041 <br /> include the following: ❑ Operating Liability <br /> IX. OWNER SIGNATURE <br /> I certify that this document and all attachments were prepared under my direction or supervision. I have inquired of the person or <br /> persons who manage the system or those persons directly responsible for gathering the information, and certify that the information <br /> submitted is, to the best of my knowledge and belief, true, accurate and complete. <br /> Property Owner or Agent Signature: <br /> Typed Name&Title: Date: <br /> X. OPERATOR CERTIFICATION <br /> I certify that this document and all attachments were prepared under my direction or supervision. I have inquired of the person or <br /> persons who manage the system or those persons directly responsible for gathering the information, and certify that the information <br /> submitted is, to the best of my knowledge and belief, true, accurate and complete. <br /> Facility Operator or Agent Signature: <br /> Typed Name&Title: Date: <br />