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APPLICATION FOR WASTE TIRE STORAGE SITE REGISTRATION
State Form 47222 (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 storage site 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. We cannot review your application until it is complete. 5. When completed, return this application form with the $500 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 site will (check one): New registration Store waste tires only Renewal of existing registration Store and process waste tires*

* Note: If you process waste tires at this site, beyond altering the tires to prevent accumulation of water, you must also complete the Application for Waste Tire Processing Operation Registration form (State Form 47221) and attach the $200 waste tire processing operation application fee required by IC 13-20-21-3. 3. Owner Information Full Name: Street Address: Mailing Address (if different): City: Day telephone: ( ) State: ZIP: ) -

Evening telephone: (

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

Evening telephone: (

5. Storage Site Information Facility name: Contact person: Physical location: County: City: Day telephone: ( ) Page 1 of 7

State:

ZIP: ) -

Evening telephone: (

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

Day telephone: ( ) Evening telephone: ( ) 7. Maximum quantity of waste tires that you will accumulate at the storage site: Determine these quantities using the Indiana Fire Code (675 IAC 22-2.3), the waste tire storage site map you provide with this application, and the conversion factors below. Show all quantities in passenger tire equivalents (PTE). Whole tires a. Total waste tires to be stored outside or in a partially enclosed structure: b. Total waste tires to be stored in a completely enclosed structure: c. Total waste tires to be stored in unlicensed vehicles: d. Other waste tires at the site that are not excluded under 329 IAC 15-1-1(b): e. Total amount of waste tires to be accumulated at this site (add a. through d.): Calculate passenger tire equivalents (PTE) using these conversions:
By weight Whole or Partial Waste Tires Partial Waste Tires multiply 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 by 0.8 21.6 1.25 0.05 to get PTE PTE cubic feet cubic yards By volume Whole Waste Tires multiply cubic feet cubic yards PTE PTE by 0.3 6.8 4 0.2 to get PTE PTE cubic feet cubic yards

Tire pieces

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 storage site. 2. A legal description of the property to be used. 3. A legible map of the waste tire storage site 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 waste tire storage site.

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4. A description of the waste tire management program you will use at this site, including all of the following: · The anticipated sources and amounts of incoming waste tires. · The names and locations of the anticipated destinations of the waste tires. · The method and schedule for draining incoming waste tires. · The method and schedule for preventing waste tires from accumulating water. Describe how they will be covered or altered. If tires will be covered, describe the covering material to be used and how it will be anchored. If tires will be altered, describe what cutting or shredding equipment will be used, how it will be obtained, and how the altered tires will be stored. If you do not own the equipment, describe how you will obtain it. · Description of the buildings, signs, notices, and alarms at this site. · Detailed description of how and where all 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 develop your own contingency plan, it must include all of the information required by 329 IAC 15-3-18. You must submit a copy of the contingency plan to the fire department with jurisdiction over this waste tire storage site. 6. The closure cost estimate required by 329 IAC 15-5-3. Costs vary by the location and physical layout of the storage site. If the department determines that the amount identified in this estimate is inadequate to close the storage site in accordance with 329 IAC 15-3-21, you will be required to provide a greater amount of financial assurance. You must update this estimate annually. 7. A certified copy of the financial assurance mechanism to be used to comply with the financial assurance requirements in 329 IAC 15-5 that clearly shows the guarantor and the amount guaranteed. The amount of financial assurance must be at least equal to the total quantity of waste tires that can be stored at the storage site (measured in passenger tire equivalents) that you identified in item A.7.e., multiplied by $2.00, unless the closure cost estimate demonstrates that a lesser amount is required. In some cases, this amount may not be adequate to close the storage site as required by 329 IAC 15-3-21. In such a case the department will require additional financial assurance before granting the registration. 8. 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. 9. A check or money order for the $500 waste tire storage site application fee required by IC 13-20-21-3. If you are going to process waste tires at this site, beyond altering the tires to prevent accumulation of water, you must also complete the Application for IDEM Waste Tire Processing Operation Registration application form and attach the $200 waste tire processing operation application fee required by IC 13-20-21-3.

PART C. Waste Tire Certificate Statements: 1. Waste Tire Storage Site 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 storage site in compliance with these requirements. Owner Name (print or type): _____________________________________________

Owner Signature: _____________________________________________

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2. Land 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 storage site in Indiana unless the person has registered the waste tire storage site 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 storage site. Land Owner Name (print or type): __________________________________________

Land Owner Signature: ___________________________________________

IMPORTANT NOTICE FOR INDIANA WASTE TIRE STORAGE SITES Indiana's rules for Waste Tire Management (329 IAC 15) require all waste tire storage sites 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 storage site, 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. You must send a copy of this plan to the fire department with jurisdiction over your storage site. 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 the storage site. This may be more than one person as long as someone is always available to manage emergencies at the storage site. 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. 329 IAC 15-5-3 requires you to submit a closure cost estimate with your application for registration. This estimate describes how much it will cost to remove all the tires at your storage site and properly close the site, and is used to decide how much financial assurance you must maintain. You must update this estimate every year on the anniversary of your registration. 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 Matthews, 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)

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CONTINGENCY PLAN FOR WASTE TIRE STORAGE SITE
You may complete this model contingency plan for your storage site, 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 storage site 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 No: Business name: Site Address: Mailing Address: City: Day telephone: ( ) State: Evening telephone: ( ) ZIP: -

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.

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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. _______________________________________ Fire Department Emergency Telephone: ( ) Administrative Telephone: ( ) -

Office of the State Fire Marshal Day telephone: (800) 423-0765 IDEM 24-Hour Emergency Response: (888) 233-7745 County Sheriff's Department for __________________________________ County Emergency Telephone: ( ) Administrative Telephone: ( ) After Hours Telephone: (800) 669-7362

Police Department for City of __________________________________ Emergency Telephone: ( ) Administrative Telephone: ( ) -

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

County Emergency Management Agency for __________________________________ County: Emergency Telephone: ( ) Administrative Telephone: ( ) -

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 storage site 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 site. · Notify emergency services listed in this plan. · Assist fire services to keep the fire from spreading, if possible. _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

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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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