Form CalRecycle500 "Waste Tire Facility Permit Application" - California

What Is Form CalRecycle500?

This is a legal form that was released by the California Department of Resources Recycling and Recovery - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the California Department of Resources Recycling and Recovery;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CalRecycle500 by clicking the link below or browse more documents and templates provided by the California Department of Resources Recycling and Recovery.

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Download Form CalRecycle500 "Waste Tire Facility Permit Application" - California

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State of California
California Department of Resources Recycling and Recovery
CalRecycle 500 (Rev. 6/14)
WASTE TIRE FACILITY
PERMIT APPLICATION
I. TYPE OF APPLICATION
TPID #:
(please print or type)
New
Permit
CalRecycle use only
Permit
Revision
Date Received:
Date Accepted:
Application
Amendment
Date Rejected:
II. TYPE OF FACILITY
Major Waste Tire Facility (5,000 or more tires)
Minor Waste Tire Facility (500 or more tires, but less than 5,000)
III. GENERAL INFORMATION
Facility Name:
Facility Mailing Address:
City:
County:
State:
Zip:
Phone:
Facility Location
:
(if different from mailing address)
City:
County:
State:
Zip:
Phone:
Assessor’s Parcel Number(s):
GPS Coordinates:
Site Acreage:
Facility Operator’s Name:
Mailing Address:
City:
County:
State:
Zip:
Phone:
Property Owner’s Name
:
(if different from operator)
Mailing Address:
City:
County:
State:
Zip:
Phone:
ssss
Cali
CA
IV. AGENCY INFORMATION
Fire Authority Agency Name:
Contact Person:
Phone:
Vector Control/Mosquito Abatement Agency Name:
Contact Person:
Phone:
V. TYPE AND QUANTITY OF WASTE TIRES
Whole Passenger
Whole Truck
Whole Tractor
Split Tires
Type of Waste
Whole Earthmover/Construction Equipment
Cut Tires
Shredded Tires
Tires Received:
Other:
Number of Whole Waste Tires/Passenger Tire Equivalents Stored or Maintained On-Site:
Maximum Capacity (Whole Waste Tires/Passenger Tire Equivalents):
Clear
Print
State of California
California Department of Resources Recycling and Recovery
CalRecycle 500 (Rev. 6/14)
WASTE TIRE FACILITY
PERMIT APPLICATION
I. TYPE OF APPLICATION
TPID #:
(please print or type)
New
Permit
CalRecycle use only
Permit
Revision
Date Received:
Date Accepted:
Application
Amendment
Date Rejected:
II. TYPE OF FACILITY
Major Waste Tire Facility (5,000 or more tires)
Minor Waste Tire Facility (500 or more tires, but less than 5,000)
III. GENERAL INFORMATION
Facility Name:
Facility Mailing Address:
City:
County:
State:
Zip:
Phone:
Facility Location
:
(if different from mailing address)
City:
County:
State:
Zip:
Phone:
Assessor’s Parcel Number(s):
GPS Coordinates:
Site Acreage:
Facility Operator’s Name:
Mailing Address:
City:
County:
State:
Zip:
Phone:
Property Owner’s Name
:
(if different from operator)
Mailing Address:
City:
County:
State:
Zip:
Phone:
ssss
Cali
CA
IV. AGENCY INFORMATION
Fire Authority Agency Name:
Contact Person:
Phone:
Vector Control/Mosquito Abatement Agency Name:
Contact Person:
Phone:
V. TYPE AND QUANTITY OF WASTE TIRES
Whole Passenger
Whole Truck
Whole Tractor
Split Tires
Type of Waste
Whole Earthmover/Construction Equipment
Cut Tires
Shredded Tires
Tires Received:
Other:
Number of Whole Waste Tires/Passenger Tire Equivalents Stored or Maintained On-Site:
Maximum Capacity (Whole Waste Tires/Passenger Tire Equivalents):
APPLICATION FORM
CalRecycle 500 (Rev. 6/14)
Page 2 of 2
VI. EQUIPMENT
Stationary Shredder
Baler
Splitter
Cutter
Types of On-Site
Processing Equipment:
Mobile Shredder
Other:
VII. PROPOSED CHANGE TO FACILITY
Design
:
(describe)
Operation
:
(describe)
Proposed Date of Change:
VIII. REQUIRED DOCUMENTS
(attachments)
Operation Plan
Environmental Form
Emergency Response Plan
(CalRecycle 501)
(CalRecycle 502)
(CalRecycle 503)
Vector Control Info.
Fire Department Info.
Property Lease Agreement
Major & Minor Waste Tire
(include approved alternatives)
(include approved alternatives)
Facility:
Fire Safety Plan
Applicable permits and approvals.
Closure Plan
For Major Waste Tire
Reduction/Elimination Plan
Financial Assurance
(CalRecycle 504)
Facility, also include the
Operating Liability
following:
IX. OWNER SIGNATURE
I certify under penalty of perjury that the information I provided for this application and for any attachments is true and accurate to the
best of my knowledge and belief. I am aware that the operator intends to operate a waste tire facility at the site specified above
pursuant to this application and understand that I may be responsible for the site should the operator fail to meet applicable
requirements.
Property Owner or Agent Signature:
Typed Name & Title:
Date:
X. OPERATOR CERTIFICATION
I certify under penalty of perjury that the information contained in this application and all attachments are true and accurate to the best
of my knowledge and belief.
Facility Operator or Agent Signature:
Typed Name & Title:
Date:
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