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APPLICATION FOR WASTE TIRE PROCESSING OPERATION REGISTRATION
State Form 47221 (R2 / 6-07) Indiana Department of Environmental Management Approved by State Board of Accounts, 2007

INSTRUCTIONS: 1. Use this form to apply for a waste tire processing operation registration under IC 13-20-13 and 329 IAC 15-3. 2. Fill in all information requested in Part A. 3. Attach all information required in Part B. 4. Be sure you have filled in this form completely and you have attached the application fee and all required information 5. When completed, return this application form with the $200 application fee and all required attachments to: IDEM Cashier's Office-OLQ 100 N. Senate Avenue ­ Mail Code 50-10C Indianapolis, IN 46204-2251 6. For more information, contact IDEM's Office of Land Quality, Solid Waste Permits Section, at (317) 232-0066. Waste Tire Account #2640-435300-101300

PART A. Print or type all information requested below: 1. This application is for a (check one): 2. This operation will (check one): New registration Process waste tires only Renewal of existing registration Process and store waste tires*

*Note: If you store 1,000 or more waste tires in conjunction with this operation (or 2,000 or more waste tires in a completely enclosed building), you must also complete the Application for Waste Tire Storage Site Registration form (State Form 47222) and attach the $500 waste tire storage site application fee required by IC 13-20-21-3.

3. Company Information. This operation is a (check one): Company name: Contact person: County(or counties) you will operate in:

Fixed operation

Mobile operation

Physical location (mobile operations must list all current and planned operating locations):

City: Day telephone: ( ) -

State: Evening telephone: ( )

ZIP: -

4. Company Owner Information: Full Name: Street Address: Mailing Address (if different): City: Day telephone: ( ) State: Evening telephone: ( ZIP: ) -

5. Company Operator Information (if different from owner): Full Name: Street Address:

Mailing Address (if different): 1 of 6

City:
Day telephone: ( ) -

State:
Evening telephone: (

ZIP:
) -

6. Property Owner Information (see IC 13-20-13-4(a)(4)): Name: Street address: Mailing Address (if different): City: Day telephone: ( ) State: Evening telephone: ( ZIP: ) -

7. Maximum quantity of waste tires that will be stored in conjunction with the processing operation: Use the Indiana Fire Code (675 IAC 22-2.3), the processing operation map, and the conversion factors below. a. Whole waste tires (Passenger Tire Equivalents): b. Shredded or cut waste tires (PTE): c. Materials derived from waste tires (PTE): d. Total of a. through c. (PTE): By Weight Whole or Partial Waste Tires
MULTIPLY

By Volume Partial Waste Tires
BY

Multiply pounds by 0.04 to obtain PTE Multiply PTE by 25 to obtain pounds Multiply tons by 80 to obtain PTE Divide PTE by 80 to obtain tons

cubic feet cubic yards PTE PTE

0.8 21.6 1.25 0.05

PART B. Attach the following information required by IC 13-20-13 and 329 IAC 15-3-3 to your application: 1. A United States Geological Survey (USGS) 72 minute topographic map or equivalent that shows the boundaries of the waste tire processing operation. 2. A legal description of the property to be used. 3. A legible map of the waste tire processing operation that shows all of the following: · Property boundaries. · On-site buildings. · Location, length, width, and height of each waste tire storage area. · Separation distances between waste tire piles. · Separation distances between tire piles and other salvaged material, lot lines, buildings, combustible materials, and other on-site activities. · Fences and other access control methods. NOTE: You must submit a copy of this map to the fire department with jurisdiction over this processing operation. 4. A description of the program that you will use to manage waste tires at this processing operation, including all of the following: · The anticipated sources and amounts of incoming waste tires. · The methods and equipment to be used to process the waste tires, and the materials that will result from the processing operation. · The names and locations of the anticipated destinations of waste tires and materials derived from waste tires. · The method and schedule for draining incoming waste tires. · The method and schedule for preventing waste tires from accumulating water. 2 of 6

· ·

Description of the buildings, signs, notices, and alarms at this processing operation. Description of how and where all tires and materials derived from waste tires will be stored.

5. The contingency plan required by 329 IAC 15-3-18. You may use the model contingency plan we provide or you may write your own. If you write your own contingency plan, it must include all of the information required by 329 IAC 15-3-18. You must submit a copy of your contingency plan to the fire department with jurisdiction over this waste tire processing operation. 6. Affidavit: Applicant Notification to Adjoining Property Owners/Occupants (State Form 49785, if required by IC 13-15-8. If the property you intend to use for this waste tire processing operation is undeveloped land or is land for which no valid existing permit has been issued, Indiana law (IC 13-15-8) requires you to notify all adjoining land owners and occupants (including those persons owning or occupying property across the street or road from your operation) within ten (10) days of submitting the application. If this requirement applies to the property described in this application, you must notify each adjoining property owner and occupant, in writing, including (1) the date this application was submitted to IDEM, and (2) a brief description of the subject of this application. You must also attach a complete list of all adjacent property owners and others potentially affected by this registration to this form, including names and complete mailing addresses for each. You may provide the adjacent property owner list and certification after you submit the application, but we cannot issue a registration until all required notices to the adjacent property owners and occupants have been completed. 7. A check or money order for the $200 waste tire processing operation application fee required by IC 13-20-21-3. Make checks payable to IDEM Waste Tire Management Fund. Remember: If you store more than 1,000 waste tires in conjunction with this operation (or more than 2,000 waste tires in a completely enclosed building), you must also complete the Application for IDEM Waste Tire Storage Site Registration application form and attach the $500 waste tire storage site registration application fee required by IC 13-20-21-3. PART C. Waste Tire Certificate Statements: 1. Waste Tire Processing Operation Owner Certification. I hereby acknowledge that I have read IC 13-20-13, IC 13-20-14, 329 IAC 15, and the relevant parts of the Indiana Fire Code (675 IAC 22-2.3). I certify that I will operate my waste tire processing operation in compliance with these requirements.

Name of Owner (print or type): ____________________________________________

Owner Signature: _____________________________________________

2. Property Owner Certification (IC 13-20-13-4(a)(4)). I am the owner of the property described in this application. I understand that a person may not maintain a waste tire processing operation in Indiana unless the person has registered the waste tire processing operation under IC 13-20-13 and holds a valid certificate of registration. I understand that the property described in this application will be used for a waste tire processing operation.

Land Owner Name (print or type): _________________________________________

Land Owner Signature: ___________________________________________

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IMPORTANT NOTICE FOR INDIANA WASTE TIRE PROCESSING OPERATIONS
Indiana's rules for Waste Tire Management (329 IAC 15) require all waste tire processing operations to prepare and keep current specific documents that (1) show how you will operate your business to minimize fire hazards and threats to human health and the environment, (2) show how you will clean up your processing operation, and (3) describe how many tires you managed in the past year and what you did with them. 329 IAC 15-3-18 requires you to prepare and submit a contingency plan with your application for registration. The contingency plan must describe how you will minimize the hazards from fires or explosions and the resulting contaminated water run-off, and how you will prevent or eliminate mosquitoes breeding in water that collects in improperly stored tires. For mobile processing operations, your plan must include how you will address these potential threats at your base facility and at all other locations where tires will be staged before you process the tires, while you are processing them, and after they are processed. You must revise this plan when required by 329 IAC 15-3-18(e). You must send a copy of this plan to the fire department with jurisdiction over your processing operation. 329 IAC 15-3-19 requires you to identify an emergency response coordinator: a person who can be contacted at any time and who is responsible for coordinating all emergency response actions at your processing operation. This may be more than one person as long as someone is always available to manage emergencies at the processing operation. Your emergency response coordinator(s) must be identified in your contingency plan. 329 IAC 15-3-20 requires you to submit an annual tire summary that reports how many tires you received during the previous calendar year, what you did with them, and how many tires you had left at the end of the year. This report must be sent to IDEM by January 31st of the following year. These documents must be submitted to: Ms. Debby Baker, Solid Waste Permits Manager IDEM Office of Land Quality 100 North Senate Avenue ­ Mail Code 65-45 Indianapolis, Indiana 46204-2251 If you have questions, contact Ms. Baker at (317) 232-0066 or (800) 451-6027, Ext. 2-0066, or e-mail at [email protected]. You may request confidential compliance assistance through the Office of Pollution Prevention and Technical Assistance by contacting Ms. Brenda Mathews, IDEM Waste Tire Coordinator at (317) 233-9341 or (800) 988-7901, Ext. 3-9341, or e-mail at [email protected]. Attachments: 329 IAC 15 Annual Waste Tire Summary Affidavit: Applicant Notification to Adjoining Property Owners/Operators (State Form 49785)

CONTINGENCY PLAN FOR WASTE TIRE PROCESSING OPERATION
You may complete this model contingency plan for your waste tire processing operation, or you may write your own. Your contingency plan must include all information required by 329 IAC 15-3-18. Purpose of the plan: To describe the actions the processing operation owner or operator and employees must take to minimize the hazards to human health and the environment from: (1) fires or explosions, (2) contaminated run-off resulting from fires or explosions, and (3) mosquitoes breeding in water that accumulates in improperly stored waste tires. Facility information: IDEM Registration Number: Business Name: Site Address: 4 of 6

Mailing Address: City: Day Telephone: ( ) State: Evening Telephone: ( ) ZIP code: -

Emergency Response Coordinator: These persons will carry out the duties described in 329-IAC 15-3-19 Primary Coordinator: Day Telephone: ( Backup Coordinator: Day Telephone: ( Backup Coordinator: Day Telephone: ( ) Evening Telephone: ( ) ) Evening Telephone: ( ) ) Evening Telephone: ( ) -

Duties of the Emergency Response Coordinator (from 329 IAC 15-3-19): The emergency response coordinator must: · Be at the waste tire storage site or waste tire processing operation or on call at all times; · Coordinate all emergency response measures carried out by the waste tire storage site or waste tire processing operation; · Be familiar with: o all aspects of the contingency plan; o the identity and telephone numbers of the fire department and other emergency services that have jurisdiction over the site; o all operations and activities at the site; o the layout of the waste tire storage site; and o the location of all records required by 329 IAC 15-3-20; and o have authority to commit resources needed to implement the contingency plan. Emergency Services Contact Information: These emergency contacts will be notified immediately after discovery of a fire or explosion, run-off resulting from a fire or explosion, or mosquitoes breeding in waste tires. Mobile operations must complete this section for each county they operate in. Fire Department / Fire Protection District: Emergency Telephone: ( ) Administrative Telephone: ( After Hours: 1-800-669-7362 ) -

Office of State Fire Marshall: 1-800-423-0765

IDEM 24-Hour Emergency Response: 1-888-233-7745 County Sheriff's Department for ___________________________ County. Emergency Telephone: ( ) Administrative Telephone: ( ) -

Police Department for City / Town of _____________________________________________________________________ Emergency Telephone: ( ) Administrative Telephone: ( ) -

County Health Department for ___________________________ County. Day Telephone: ( ) After Hours Telephone: ( ) -

County Emergency Management for ___________________________ County. Emergency Telephone: ( ) Administrative Telephone: ( 5 of 6 ) -

Facility Site Plan. A facility site plan that shows all of the following is attached to this contingency plan: · Facility boundaries and property lines. · Buildings, showing occupancy of each building and any hazardous materials. · Fences, vehicle access points, and access gates. · Tire and rubber product storage areas. The length, width and height of each storage area must be shown. · Enclosed trucks/trailers used to store tires. · Fuel storage areas showing type of fuel stored. · Separation distances between tire storage areas, and between storage areas and fences, property boundaries, buildings, and other salvaged material. · Fire hydrants, fire extinguishers, and other fire control devices. · Surface water drainage flow from tire storage areas, showing sewer and storm water drains and points where run-off can be stopped before it leaves the property. Contingency Plan Action Steps. These are the specific steps that the owner or operator and processing operation employees will take in response to site emergencies. FIRE OR EXPLOSION: In the event of a fire, explosion or other emergency, the emergency response coordinator will: · Evacuate all workers from the processing operation. · Notify emergency services listed in this plan. Assist fire services to keep the fire from spreading, if possible. ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ RUN-OFF RESULTING FROM FIRE OR EXPLOSION: In the event of a fire, explosion or other emergency, the emergency response coordinator will control or contain the flow of contaminated run-off by taking the following steps: ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ MOSQUITOS BREEDING IN WASTE TIRES: · Mosquito control will be done by draining accumulated water from all waste tires on the day they arrive and as often as necessary after that to prevent water accumulating in the tires. · Within 7 days after arrival on site, all tires will be covered or altered by shredding, chopping, drilling, or slitting and stacking so the tires will not collect water. · The emergency response coordinator will identify mosquitoes breeding in waste tires by _______________________ _____________________________________________________________________________________________ · · · If control of water accumulation has not been done or is ineffective, and mosquitoes are found breeding in the waste tires, the emergency response coordinator will do the following: Immediately drain all remaining water from the tires. Use an EPA registered and Indiana licensed mosquito larvicide. Name of larvicide: __________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

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