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APPLICATION FORM CalRecycle 500(Rev.6/14) <br /> Page 2 of 2 <br /> VI. EQUIPMENT <br /> Types of On-Site X Stationary Shredder ❑ Baler X Splitter X Cotter <br /> Processing Equipment: ❑ Mobile Shredder X Other. I Debcader <br /> VII. PROPOSED CHANGE TO FACILITY <br /> ❑ Design.(descnbe): <br /> X Operation(dcscnbe): Use storage capacity as outlined in original permit for TDA/TDP,increase financial assurance. <br /> Proposed Date of Change: When permit renewed to allow for increase storage. <br /> VIII. REQUIRED DOCUMENTS(attachments) <br /> x Operation Plan x Environmental Form x Emergency Response Plan <br /> C&M a 501 (CAM--ick 502) $03 <br /> Vector Control Info. x Fire Deparoment Info. x Prop,Lease Agreement <br /> Major&Minor Waste Tire x (inctude appmved ahmativw) (inctude eppmved attenm6yes) <br /> Facility. x Fire Safety Plan <br /> x Applicable permits and approvals. <br /> For Major Waste Tire x Closure Plan ❑ Reduction/Elimination Plan x Financial Assurance <br /> Facility,also include the S09 <br /> following: x Operating Liability <br /> IX. OWNER SIGNATURE <br /> I certify under penalty of perjury that the information I provided for this application and for any attachments is true and accurate to the <br /> best of my knowledge and belief. I am aware that the operator intends to operate a waste tire facility at the site specified above <br /> pursuant to this application and understand that I may be responsible for the site should the operator fail to meet applicable <br /> requirements. <br /> Property Owner or Agent Signature: <br /> Typed Nam &Title: Mark W.Hope,Member Date: January 29,2015 <br /> X. OPERATOR CERTIFICATION <br /> I certify under penalty of perjury that the information contained in this application and all attachments are true and accurate to the best <br /> of my knowledge and belief. ; <br /> Facility Operator or Agent Signature: `� .�`✓ <br /> Typed Name&Title: Mark W.Hope,President Date: January 29,2015 <br />