Reset Form APPLICATION FOR WASTE TIRE STORAGE SITE REGISTRATION State Form 47222 (R3 / 10-11) Approved by State Board of Accounts, 2011 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INSTRUCTIONS: 1. Use this form to apply for a Waste Tire Storage Site Registration under IC 13-20-13 and 329 IAC 15. 2. Fill in all information requested in Part A. 3. Attach all information required in Part B. 4. Be sure that 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 three (3) copies of application form and all required attachments with the $500.00 application fee to: IDEM Cashier’s Office – OLQ 100 N. Senate Avenue – Mail Code 50-10C Indianapolis, IN 46204-2251 6. Make checks payable to IDEM Waste Tire Management Fund. 7. For more information, contact IDEM’s Office of Land Quality, Solid Waste Permits Section, at (317) 232-4473. Waste Tire Account #35310-421650-94942 Part A. Print or type all information requested below: New registration 1.This application is for a (check one): 2. For Renewals, enter existing registration number: Renewal of existing registration Note: If you process waste tires in conjunction with this site, you must also complete the Application for Waste Tire Processing Operation Registration (State Form 47221) and attach the $200.00 Waste Tire Processing Operation Application fee required by IC 13-20-21-3. In addition, all storage (no minimum amount) on site must comply with the Indiana Fire Code (675 IAC 22-2.4). 4. Business Information Business Name: Owner Full Name: Business Street Address: City: State: Mailing Address (if different): City: State: Day telephone: ( ) Email Address: Business Contact Name (if different): Day telephone: ( ) Email Address: 5. Business Owner Information Full Name: Street Address: City: State: Mailing Address (if different): City: State: Day telephone: ( ) Email Address: ZIP: County: ZIP: Evening telephone: ( County: ) - Evening telephone: ( ) ZIP: ZIP: Evening telephone: ( - County: ) County: - 7. Property Owner Information (if different from Business Owner) Full Name: Street Address: Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com City: State: Mailing Address (if different): City: State: Day telephone: ( ) Email Address: ZIP: ZIP: Evening telephone: ( County: County: ) - 8. 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). PTE 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.): Note: To calculate passenger Tire Equivalents (PTEs) use the conversion factors found in Part D of this application. 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 storage site as required by 329 IAC 15-3-3 (b) (3). 4. A description of the program that you will use to manage waste tires at this storage site, including all of the following:  The anticipated sources and amounts of incoming waste tires.  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. 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. Please note, altering tires may require a Waste Tire Processing Operation Registration. Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com  Description of the buildings, signs, notices, and alarms at this storage site.  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. Additionally, you must submit a copy of your 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. The closure cost estimate must be based on the costs of contracting a third party to complete the closure. 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. The estimate must be done on the Registered Tire Storage Site Closure Cost Estimate (State Form 53784). 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 based on the maximum number of waste tires that can be accumulated at the site at any one time. In some cases, this amount may not be adequate to close the storage site as required by 329 IAC 15-3-21. In this 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 the property you intend to use for this Waste Tire Storage Site 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. Part C. Waste Tire Certificate Statements: 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. Name of Owner (Print or Type): Business Owner Signature: Date (mm/dd/yyyy): Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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. Note: Be advised that any property that will also be used as a Waste Tire Processing Operation and/or Waste Tire Transporter Operation, must also register as a Waste Tire Processing Operation and/or Waste Tire Transporter Operation. Name of Land Owner (Print or Type): Land Owner Signature: Date (mm/dd/yyyy): Part D. Important information for Waste Tire Storage Sites: Conversion Factors: Average weight of one whole passenger tire = 20 lbs = 1 PTE (Passenger Tire Equivalent) Average weight of one whole semi-truck tire = 100 lbs = 5 PTEs 100 passenger tires = 1 ton (2,000 lbs) 20 semi-truck tires = 1 ton (2,000 lbs) 10 PTEs/yd3 3 semi-truck tires/yd3 27-30 PTEs/yd3 42-47 PTEs/yd3 Whole passenger tires Whole “semi” truck tires Single pass/rough shreds 2-inch shreds APPROXIMATE NUMBER OF WHOLE PTEs IN EACH PILE PILE SIZE 10 FT 11 FT 12 FT 13 FT 14 FT (in feet) HIGH HIGH HIGH HIGH HIGH 50’ X 50’ 100’ X 50’ 100’ X 100’ 150’ X 100’ 200’ X 200’ 1 ACRE 2 ACRE 3 ACRE Note: 1. 2. 3. 9,259 18,519 37,037 55,556 148,148 161,333 322,667 484,000 10,185 20,370 40,741 61,111 162,963 177,467 354,933 532,400 11,111 22,222 44,444 66,667 177,778 193,600 387,200 580,800 12,037 24,074 48,148 72,222 192,593 209,733 419,467 629,200 12,963 25,926 51,852 77,778 207,407 225,867 451.733 677,600 20 FT HIGH 18,519 37,037 74,074 111,111 296,296 322,667 645,333 968,000 200 lbs/yd3 300 lbs/yd3 550-600 lbs/yd3 850-950 lbs/yd3 CONSTANT for one foot height increase or decrease 926 1,852 3,704 5,555 14,815 16,133 32,267 48,400 The above table is based on 10 whole PTEs/yd3 and 43,560 square feet per acre. Compaction will influence the total. Compaction is influenced by overall height of pile and length of storage time in pile. Be advised Fire Marshall Codes (675 IAC 22-2.4) prohibit tire piles greater than 5,000 square feet in continuous area, 50,000 cubic feet in volume, or 10 feet in height. Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 the storage site in the event that operations cease, 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 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 your 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: Waste Tire Storage Site/Waste Tire Processing Operation (State Form 52716) 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 Registered Tire Storage Site Closure Cost Estimate (State Form 53784) 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. This form must re-submitted to IDEM by January 31st of every year. In addition, you must submit this form whenever a change in the removal process increases the closure cost estimate. These documents must be submitted to: Indiana Department of Environmental Management Solid Waste Permits Section IGCN 1101 100 N. Senate Avenue – MC 65-45 Indianapolis, IN 46204-2251 If you have questions, contact the Solid Waste Permits Section at (317) 232-4473 or (800) 451-6027 and ask for Ext. 2-4473. You may request confidential compliance assistance through the Office of Pollution Prevention and Technical Assistance by calling (317) 232-8174 or (800) 988-7901, Ext. 2-8174. Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com