Laserfiche WebLink
APPLICATION FORM CalRecycle 500(Rev.6/14) <br /> Page 2 of 2 <br /> VI. EQUIPMENT <br /> I'ypes of On-Site ® Stationary Shredder ❑ Baler ❑ Splitter ❑ Cutter <br /> Processing Equipment: ❑ Mobile Shredder ® Other: Crumb rubber production equipment <br /> VII. PROPOSED CHANGE TO FACILITY <br /> ❑ Design(describe): <br /> ❑ Operation(describe): <br /> Proposed Date of Change: <br /> VIII. REQUIRED DOCUMENTS(attachments) <br /> ® Operation Plan ® Environmental Form ® Emergency Response Plan <br /> I C*1Ravc1e 5011 (CelRMVCIC 502) (CAKa le 503) <br /> ® Vector Control Info. ® Fire Department Info. ❑ Property Lease Agreement <br /> Major&Minor Waste Tire (include approved altematives) (include approved altematives) <br /> Facility: <br /> ® Fire Safety Plan <br /> ® Applicable permits and approvals. <br /> For Major Waste Tire ® Closure Plan ® Reduction/Elimination Plan ® Financial Assurance <br /> Facility,also include the 1Ca1Rtcvcjc5041 <br /> following: ® 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 Name&Title: Dr.Barry Takallou,Ph.D.,P.E.President&CEO Date: <br /> X. OPERATOR CERTIFICATION <br /> I certify under penalty of perjury that the information contained in this application and all attachments arc true and accurate to the best <br /> of my knowledge and belief. <br /> Facility Operator or Agent Signature: �l <br /> Typed Narne&Title: I Dr.Barry Takallou,Ph.D.,P.E.President&CEO Date: <br />