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APPLICATION 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 <br /> ® Other: TTire Bin <br /> VII. PROPOSED CHANGE TO FACILITY <br /> ❑ Design(describe): <br /> ❑ Operation(describe): <br /> ❑ Administrative(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 Department Info. ® Property Lease Agreement <br /> ® Verification that applicable local,state,and federal permits and approvals have been acquired. <br /> For Major WTFs,also ❑ Cl,°u 504P1an ❑ Reduction/Elimination Plan <br /> El Financial Assurance <br /> include the following: <br /> ❑ Operating Liability <br /> IX. OWNER SIGNATURE <br /> 1 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: James A.Capis,Owner Date: 4/26/06 <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: James A.Capis,President Date: 4/26/06 <br />