California Code of Regulations › Title 14 - Natural Resources › Division 7 - Department of Resources Recycling and Recovery › Chapter 9 - Planning Guidelines and Procedures for Preparing and Revising Countywide Integrated Waste Management Plans › Appendix A - Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
CIWMB Form Number 36 (rev. 11/94)
State of California Oil Recycling Program Fee Exemption
				  Certificate
___________________________
Name of Purchaser
___________________________
Address of Purchaser
___________________________
CIWMB Oil Manufacturer Registration Number
(Indicate "Not Applicable" if the purchaser is not required
				  to have a registration number)
I HEREBY CERTIFY that the oil products described herein which
				  I am purchasing from:___________________________
will be used in the following exempt manner:
( ) the oil will be exported from California
( ) the oil will be used in a vessel operated in interstate
				  or foreign commerce
( ) the oil is purchased in bulk (oil which is in nonpackaged
				  form in containers larger than 55 gallons) and used in:
( ) motor trucks of three or more axles which are more than
				  10,000 pounds gross vehicle weight (Vehicle Code Section
				  34500(a),
				  or
( ) truck tractors (Vehicle Code Section
				  43500(b)).
In the event the lubricating oil purchased is not used as
				  indicated above, it is understood that I will report and pay the appropriate
				  fee for the reported number of such quarts or gallons.
Description of products to be purchased or being purchased
				  (including number of gallons):
___________________________
___________________________
For "Qualified" Exemption Certificates, attach purchase
				  order.
Date: ______________________________
Signature of Purchaser or Authorized
				  Agent:___________________________
Printed Name and Title:___________________________
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State of
						  California
Department of Resources Recycling and
						  Recovery
CalRecycle-60 (1/08)
P.O. Box 4025 *
						  Sacramento, CA 95812
APPLICANT: This application is
						  a:
CalRecycle Use Only
TPID:
Reviewed
New Application
[]
Change in Business
						  Name, Owner or Vehicle Ownership
[]
By___________________________
Renewal
[]
Change in Facility Address,
						  Mailing Address or Phone Number
[]
Add/Delete Vehicle
[]
Replacement
						  Decal
[]
Date Issued___________________________
Waste Tire Hauler Registration
				  Application
Pursuant to Section
				  42950 et seq. of the Public
				  Resources Code, a waste tire hauler shall submit the following information on
				  this form in order to obtain a Waste Tire Hauler Registration and approval to
				  transport used or waste tires.
APPLICANT: COMPLETE (TYPE OR PRINT IN INK) ITEM 1
				  THROUGH 11. IF A SPECIFIC ITEM DOES NOT APPLY TO YOUR COMPANY, ENTER "N/A", FOR
				  NOT APPLICABLE INCOMPLETE OR PHOTOCOPIED FORMS MAY BE REJECTED.
1. Name of Business 
				  * :
				  .___________________________
2. Please check the appropriate box for the Business listed
				  above:
[] Individual [] Sole Proprietorship [] Limited Liability
				  Company [] Corporation [] Political Subdivision
3. Facility Address: (The location of the business including
				  where vehicles and used or waste tires are stored)
Street___________________________
___________________________
City
__________________________________________________________________________________________
State
__________________________________________________
Zip Code
___________________________
4. Business Owner: (Individual, CEO, President, Managing
				  Partner(s)):
________________________________________
/ Phone Number
___________________________
Social Security Number __________ - __________ - __________ 
				  ** Driver License/Identification
				  Number ___________________________
5. Business Manager (if different from Business
				  Owner):
__________
/ Phone Number
___________________________
6. Other business names of the company (DBA's):
___________________________
7. Mailing address of company:
___________________________
City
__________________________________________________________________________________________
State
__________________________________________________
Zip Code
8. Attach proof of bond. (Form CIWMB-61)
9. Have you at any time had a license, permit or registration
				  issued by the Department that was the subject of a disciplinary action?
Yes [] or No [] if yes, please explain.
* Name of individual, sole
				  proprietorship, co-partnership, Limited Liability Company, corporation, or
				  political subdivision applying for registration.
** Pursuant to Family Code Section
				  17520(d),
				  persons applying for issuance or renewal of any license or other authorization
				  to engage in a business, occupation, or profession under any of the laws
				  administered by the Department, must provide their social security numbers to
				  the Department. The Department uses this information to match their names to
				  the names on the list provided by the Department of Child Support Services, and
				  to respond to requests for information made by child support agencies. Please
				  be advised that this social security number may be used for the Department
				  enforcement and/or collection of penalties when needed. Please note that this
				  section does not apply to Limited Liability Companies, corporations, or
				  political subdivisions.
10. I understand that any misstatement or omission of
				  material fact on this application shall be cause for punitive action or may be
				  grounds for criminal, civil, or administration actions, including denial,
				  revocation, or suspension of the waste tire hauler registration. I certify
				  under penalty of perjury under the laws of the State of California that the
				  information on this application form is true and correct.
___________________________
___________________________
Signature of Authorized Agent
Date
___________________________
___________________________
Printed Name of Authorized Agent
Title of Authorized Agent
No registration application fee is required. Incomplete
				  applications will be returned, and applicant will not be considered
				  registered.
RETURN COMPLETE REGISTRATION APPLICATION
						  TO:
Tire Hauler Compliance Section
Compliance Evaluation and enforcement
						  Division
Department of Resources Recycling and
						  Recovery (CalRecycle)
P.O. Box 4025
Sacramento, CA 95812
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State of California
California Integrated Waste
						  Management Board
CIWMB-61 (Rev. 1/08)
WASTE TIRE HAULER BOND
BOND NUMBER____________________
KNOW ALL PEOPLE BY THESE PRESENTS:
That we, The
				  Undersigned________________________________________, whose address for service
				  is ________________________________________, as Principal, and
				  ______________________________, a corporation organized and existing under the
				  laws of the State of ______________________________ and authorized to transact
				  a general surety business in the State of California, whose address for service
				  is ______________________________, as Surety, are held and firmly bound unto
				  the State of California in the sum of TEN THOUSAND DOLLARS ($10,000) lawful
				  money of the United States, for the payment of which well and truly to be made,
				  we bind ourselves, our heirs, executors, administrators, personal
				  representatives, successors and assigns, jointly and severally, firmly by these
				  presents.
WHEREAS, the Principal is required by the provisions of
				  Section
				  42955
				  of the Public Resources Code to file or have on file a bond as therein
				  prescribed in the amount of ten thousand dollars ($10,000) and said Principal
				  admits it is so required and
WHEREAS, the above-named Principal, pursuant to California
				  Senate Bill No. 744 (McCorquodale), Chapter 511, Statutes of 1993, an act to
				  amend Section
				  42889 of, and to add Chapter 19
				  (commencing with Section
				  42950) to Part 3 of Division 30
				  of, the Public Resources Code, relating to used and waste tire haulers, is
				  applying to the California Integrated Waste Management Board for a registration
				  to engage in transportation of used and waste tires as defined in California
				  Statutes of 1993, Chapter 511, Part 3 of Division 30, Chapter 19, Article 1,
				  Section 42950 et seq., at the following
				  location:
___________________________
__________________________________________________;
				  and
NOW THEREFORE, the conditions of the foregoing obligation are
				  that if the Principal above named shall faithfully comply with all and be
				  subject to all applicable statutes, rules, and used and waste tire hauler
				  registration conditions of the State of California, then this obligation shall
				  be null and void, otherwise to remain in full force and effect.
PROVIDED, HOWEVER, this bond is issued subject to the
				  following express conditions:
1. This bond shall be effective on __________ day of
				  ____________________, 20___, and shall run concurrently with the period of the
				  registration granted to the Principal, and shall remain in full force and
				  effect for any renewals thereof, provided, however, that the penalty of said
				  bond shall not be cumulative from year to year, and the total liability of the
				  Surety herein shall not exceed the sum of ten thousand dollars ($10,000),
				  regardless of the number of registration periods for which said bond is in
				  force.
2. The conditions of this bond are as set forth in Chapter 19
				  (commencing with Section
				  42950) of Part 3 of Division 30 of
				  the Public Resources Code and any regulations adopted to carry out this chapter
				  or any of the California Integrated Waste Management Board's duties or
				  responsibilities imposed pursuant to this chapter.
State of California
California Integrated Waste
						  Management Board
CIWMB-61 (2/02)
Waste Tire Hauler Bond
3. This bond is executed by the surety to comply with the
				  provisions of Chapter 19 (commencing with Section
				  42950) of Part 3 of Division 30 of
				  the Public Resources Code and applicable regulations and of Chapter 2, Title
				  14, Part 2 (commencing with Section
				  995.010) the Code of Civil
				  Procedure and said bond shall be subject to all of the terms and provisions
				  thereof.
4. Any person claiming against said bond may bring an action
				  on this bond, provided that written claim of such right of action shall be made
				  to a principal or the surety company within two years after the injury.
5. It shall be the responsibility of the Surety to notify the
				  California Integrated Waste Management Board immediately upon the payment of
				  any funds which decreases the liability of the Surety under this bond, or if
				  there is outstanding a claim for which the principal and/or bonding company is
				  liable.
6. This bond may be canceled by the Surety by sending a
				  notice of cancellation by registered or certified mail to the Tire Hauler
				  Compliance Section, Compliance Evaluation and Enforcement Division, P.O. Box
				  4025, Sacramento, CA 95812-4025. The surety shall at the same time mail or
				  deliver a copy of the notice of cancellation to the Principal. [See Code of
				  Civil Procedure Section
				  996.310
				  et. seq.] Such cancellation shall take effect 30 days from the date said notice
				  of cancellation is received by the California Integrated Waste Management
				  Board.
IN WITNESS WHEREOF, the above named parties have executed
				  this instrument the __________ day of __________, 20___.
Corporate
						  Seal
___________________________
of Principal
Principal
(if corporation)
By___________________________
(Title)
ACKNOWLEDGMENT OF SURETY
I certify (or declare) under penalty of perjury under the
				  laws of the State of California that I have executed the foregoing bond under
				  an unrevoked power of attorney.
Executed in______________________________(City, State) on
				  ____________________(Date), under the laws of the State of California.
Corporate Seal
___________________________
of Surety
Signature of Attorney-In-Fact for
						  Surety
___________________________
Printed or Typed Name of Attorney-In-Fact for
						  Surety
State of California
California Integrated Waste
						  Management Board
CIWMB-62 (2/02)
1001 "I" Street * P.O. Box 4025
						  * Sacramento, CA 95812
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INSTRUCTIONS FOR COMPLETING WASTE TIRE
				  HAULER MANIFEST (CIWMB-62)
ALL PARTIES MUST KEEP COPIES OF THE MANIFESTS FOR THREE YEARS
				  AND MAKE THEM AVAILABLE TO AUTHORIZED REPRESENTATIVES OF THE CALIFORNIA
				  INTEGRATED WASTE MANAGEMENT BOARD UPON REQUEST.
PART 1. TO BE COMPLETED BY WASTE TIRE DEALER/TIRE
				  GENERATOR REPRESENTATIVE
1. Representative of the tire dealer/waste tire generator
				  completes this section.
2. Complete the name of the company, address, city, state,
				  zip, county, and phone number (Address stamp is acceptable on each
				  copy).
3. Show the number of whole tires and/or processed tires in
				  this shipment.
For example, a shipment may contain 100 whole tires and/or
				  100 pounds of processed tires.
4. Certify that the information provided is true and correct
				  in Part 1 and Part 2(a) and Part 3(a), sign, and date.
5. Keep the PINK copy of the manifest for record
				  keeping.
6. May require the hauler to return the BLUE copy of the
				  manifest with the destination site certification signature as proof of delivery
				  to an authorized waste tire site.
PART 2. TO BE COMPLETED BY WASTE TIRE HAULER
				  REPRESENTATIVE
1. Driver representing the registered waste tire hauler
				  completes this section.
2. Complete Section
				  2(a) PRIOR TO
				  LEAVING THE TIRE GENERATOR'S PREMISES
3. Complete Section
				  3(a) PRIOR TO
				  LEAVING THE TIRE GENERATOR'S PREMISES (Address stamp is acceptable on each
				  copy).
4. Complete Section
				  2(b) PRIOR TO
				  ARRIVAL AT THE WASTE TIRE DESTINATION SITE
5. Certify that the information provided is true and correct,
				  sign and date.
6. Keep the WHITE (original) copy of the manifest for record
				  keeping.
PART 3. WASTE TIRE DESTINATION SITE
				  CERTIFICATION
1. Representative of the receiving facility completes this
				  section.
2. Verify Section
				  3(a)
				  information.
3. Complete Section
				  3(b).
4. Verify number/quantity of tires received.
5. Certify that the information provided is true and correct,
				  sign and date.
6. Keep the YELLOW copy of the manifest for record
				  keeping.
___________________________
The following Public Resource Code Sections reference civil
				  penalties or administrative penalties which may result from falsification of
				  this manifest:
Public Resources Code, Division 30, Chapter 19, Section
				  42962(a) states:
				  "Any person who intentionally, or negligently, violates any permit, rule,
				  regulation, standard, or requirement issued or adopted pursuant to this
				  chapter, shall be liable for a civil penalty not to exceed ten thousand dollars
				  ($10,000) for each violation of a separate provision or for continuing
				  violations for each day that violation continues. Liability under this section
				  may be imposed in a civil action."
Public Resources Code, Division 30, Chapter 19, Section
				  42962(b) states:
				  "In addition to the civil penalty which may be imposed pursuant to subdivision
				  (a), the board may impose civil penalties administratively in an amount not to
				  exceed one thousand dollars ($1,000) for each violation of a separate provision
				  or for continuing violations for each day that violation continues, for any
				  person who intentionally or negligently violates any permit, rule, regulation,
				  standard, or requirement issued or adopted pursuant to this chapter."
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Instructions for Completing Registration Application:
Fill out this application form completely and accurately.
				  After the Enforcement Agency has review(ed) the application, it will determine
				  whether it meets the requirements of section
				  18104.1. If the Enforcement Agency
				  finds that the application is complete and correct, a copy of this application
				  and a permit will be returned to you. If the application is not found to be
				  complete and correct it will not be accepted for filing. For additional
				  information on the procedure used for processing this application refer to
				  Title 14 of the California Code of Regulations, Section
				  181094 et. seq.
Facility Name: The legal name of the facility.
Facility Address/Location: The address of the facility and
				  the a description of the location if different.
Facility Operator/Land Owner: Provide both the mailing
				  addresses and the location/address where process may be served.
Section Authorizing Eligibility:
You must determine the appropriate Section in Chapters 3 or
				  3.1 of Division 7 of Title 14 of the California Code of Regulations that
				  authorizes eligibility. After determining the appropriate section list it on
				  the application.
Site Capacity: Total capacity of material that can be stored
				  at the site any one time.
Peak Loading: Is the largest projected waste/material
				  quantity to be received by an operation on any day of operation.
Annual Loading: Is the maximum amount of waste/material to be
				  handled by an operation annually.
Days and hours of Operation: The days and hours that the
				  facility is in operation.
Facility Size: The total acreage of the site.
Operating area: The total acreage that is used for all
				  operations.
Traffic: State the maximum number of vehicles that will enter
				  and haul incoming material or remove material on a daily basis.
The operator is required to supply conformance finding
				  information. Whichever one of the two statements above is appropriate to your
				  operation must be checked. To help you in making this determination, you can
				  contact the Enforcement Agency, Local Task Force, or other solid waste planning
				  agency in your city or county.
The application must include a site map and a location map.
				  The site map should include, but not be limited to, operations areas and their
				  relationships to property boundaries, adjacent land uses, proposed drainage
				  systems, any excavation areas, and any other portions of the site dedicated to
				  a specific use. The location map should show the general location of the
				  operation at a scale size minimally equivalent to 1:24,000 USGS topographical
				  quadrangle.
This application must be signed, under penalty of perjury, by
				  both the land owner and the operator.Nonhazardous Petroleum Contaminated Soil
				  Regulatory RequirementsDecember 13, 1995
State of California
California
						  Integrated Waste
CIWMB FORM 90 (rev. 12/96)
Management Board
STANDARDIZED CONTAMINATED SOIL SOLID WASTE
						  FACILITIES PERMIT
1. Facility/Permit Number
						  (SWIS):
2. Facility
						  Name:
Address/Location:
3. Enforcement Agency:
Address:
4. Signature of Enforcement Agency Approving
						  Officer:
6. Date Signed:
5. Please Print or Type Name and Title of Approving
						  Officer:
7. Date Received by CIWMB:
8. Signature of CIWMB Approving Officer:
10. Date Signed:
9. Please Print or Type Name and Title of Approving
						  Officer:
11. Date of Permit Issuance:
12.
						  Permit Review Due Date:
The facility for which this permit has been
						  issued shall only be operated in accordance with the description provided in
						  the application pursuant to Section
						  18105.1 and Report of Contaminated
						  Soil Disposal Site Information pursuant to Section
						  18224.
13. Legal Description of Facility:
						  (description may be attached)
14. Findings:
a. This permit is consistent with standards adopted by the
				  California Integrated Waste Management Board, pursuant to Public Resources Code
				  Section
				  44010.
b. An environmental determination has been filed with the
				  State Clearing House (# ____________________) for all facilities that are not
				  exempt from CEQA and documents pursuant to Public Resources Code Section
				  21081.6.
c. The following authorized agent
				  ______________________________ has made the determination that the facility is
				  consistent with the applicable general plan, as required by Public Resources
				  Code, Section
				  50000.5(a).
d. The operation of this facility is consistent with the [ ]
				  County Solid Waste Management Plan (50000), or the [ ] County Integrated Waste
				  Management Plan (50001).
e. The design of the proposed facility or the design and
				  operation of an existing facility, as appropriate, is in compliance with State
				  Minimum Standards for Contaminated Soil Operations and Facilities Regulatory
				  Requirements, Title 14, Division 7, Chapter 3, Article 5.6 of the California
				  Code of Regulations.
___________________________
15. In addition to this permit, the facility may have one or
				  more of the following permits or restrictions on its operations. Persons
				  seeking information regarding these items should contact the appropriate
				  regulatory agency.
CIWMB Report for Contaminated Soil Disposal Site
				  Information
State Water Resources Control Board/Regional Water Quality
				  Control Board Waste Discharge Requirements or Waiver
National Pollutant Discharge Elimination System (Stormwater)
				  Permit
Fire Protection District Findings
Mitigation and Monitoring Measures (pursuant to the
				  California Environmental Quality Act)
Conditional Use Permit
California Environmental Quality Act Environmental Impact
				  Report or Negative Declaration
Air Pollution Permits and Variances
Coastal Commission Restrictions
___________________________
16. Terms and Conditions:
a. The operator shall comply with applicable state minimum
				  standards set forth in Title 14, Division 7, Chapter 3, Article 5.6 of the
				  California Code of Regulations.
b. The operator shall comply with all mitigation and
				  monitoring measures developed in accordance with a certified environmental
				  document filed pursuant to Public Resources Code Section
				  21081.6.
c. The operator shall maintain a copy of this standardized
				  permit at the facility or at a location agreed upon by enforcement agency and
				  board personnel, to be available at all times to facility, enforcement agency,
				  and board personnel.
d. The operator shall maintain and make available for
				  inspection by the enforcement agency and board all correspondence and reports
				  provided to other regulatory agencies that have jurisdiction over the
				  facility.
e. The design capacity of ___ tons or cubic-yards per day of
				  contained soil being disposed of shall not be exceeded.
f. Additional clarifying information concerning the design
				  and operation of the contaminated soil facility shall be furnished upon written
				  request of the enforcement agency, or the board.
g. Unless specifically permitted or allowed under Title 14,
				  Division 7, Chapter 3, Article 5.6 of the California Code of Regulations, the
				  facility shall not accept the following materials:
(1) Designated wastes as defined in Title 23, Chapter 15,
				  Section 2522 of the California Code of
				  Regulations
(2) Hot Ashes/Burning materials
(3) Medical wastes as defined in Section
				  25023.2 of the Health & Safety
				  Code
(4) Hazardous Wastes as defined in Section
				  25117 of the Health & Safety
				  Code
(5) Liquid Wastes as defined in Title 23, Chapter 15, Section
				  2601 of the California Code of
				  Regulations)
h. Discharge of wastes off-site are prohibited.
i. The facility, if located outside of a city, shall be
				  maintained in compliance with the flammable clearance provisions, pursuant to
				  Public Resources Code Section
				  44151.
___________________________
State of
						  California
California Integrated Waste
CIWMB FORM 98 (new
						  7/96)
Management Board
STANDARDIZED NONHAZARDOUS ASH SOLID
						  WASTE FACILITY PERMIT
1
. Facility/Permit Number
						  (SWIS):
2. Facility Name and Address/Location:
3.
						  Operator Name and Mailing Address:
4. Owner Name and Mailing Address:
5.
						  Enforcement Agency and Address:
6. Signature of Enforcement Agency Approving
						  Officer:
8. Date Signed:
7. Please Print or Type Name and Title of Approving
						  Officer:
9. Date Received by CIWMB:
10. CIWMB Concurrence Date:
11. Signature of CIWMB Approving Officer:
13.
						  Date Signed:
12. Please Print or Type Name and Title of Approving
						  Officer:
14. Date of Permit Issuance:
15. Permit Review
						  Due Date:
The facility for which this permit has been
						  issued shall only be operated in accordance with the description provided in
						  the application pursuant to Section
						  18105.1 and Report of Nonhazardous
						  Ash Disposal Site Information pursuant to Section
						  18226. (Applicants may use the
						  Standardized Permit Application CIWMB 92).
16. Legal Description of Facility:
						  (description may be attached)
___________________________
17. Findings:
a. This permit is consistent with standards adopted by the
				  California Integrated Waste Management Board, pursuant to Public Resources Code
				  Section
				  44010.
b. [ ] A CEQA exemption (state the type, and identify section
				  of exemption, or N/A), ___________________________________, or [ ] a (state
				  type of environment document, date, and SCH#) has been filed with the State
				  Clearinghouse and adopted or certified. Where mitigation measures have been
				  identified, a Mitigation Reporting or Monitoring Program has been adopted as
				  part of the project pursuant to Public Resources Code Section
				  21081.6.
c. The following authorized agent
				  ______________________________ has made the determination that the facility is
				  consistent with the applicable general plan, as required by Public Resources
				  Code, Section
				  50000.5(a).
d. The operation of this facility is consistent with the [ ]
				  County Solid Waste Management Plan (50000), or the [ ] County Integrated Waste
				  Management Plan (50001).
e. The design of the proposed facility or the design and
				  operation of an existing facility, as appropriate, is in compliance with State
				  Minimum Standards for Nonhazardous Ash Operations and Facility Regulatory
				  Requirements, Title 14, Division 7, Chapter 3, Article 5.8 of the California
				  Code of Regulations.
f. Public Resources Code Section
				  44009
				  has been complied with.
___________________________
18. In addition to this permit, the facility may have one or
				  more of the following permits or restrictions on its operations. Persons
				  seeking information regarding these items should contact the appropriate
				  regulatory agency.
Report of Nonhazardous Ash Disposal Site Information
State Water Resources Control Board/Regional Water Quality
				  Control Board Waste
Discharge Requirements or Waiver
National Pollutant Discharge Elimination System (Stormwater)
				  Permit
Fire Protection District Findings
Mitigation and Monitoring Measures (pursuant to the
				  California Environmental Quality Act)
Conditional Use Permit/Land Use Permit
California Environmental Quality Act Environmental Impact
				  Report or Negative Declaration
Air Pollution Permits and Variances
Coastal Commission Restrictions
Other Permits may also apply
___________________________
19. Terms and Conditions:
a. The operator shall comply with applicable state minimum
				  standards set forth in Title 14, Division 7, Chapter 3, Article 5.8 of the
				  California Code of Regulations.
b. The operator shall comply with all applicable mitigation
				  and monitoring measures that are to be implemented with the enforcement
				  agency.
c. The operator shall maintain a copy of this standardized
				  permit at the facility or at a location agreed upon by enforcement agency, to
				  be available at all times to facility, enforcement agency, and CIWMB
				  personnel.
d. The operator shall maintain and make available for
				  inspection by the enforcement agency and CIWMB all correspondence and reports
				  provided to other regulatory agencies that have jurisdiction over the
				  facility.
e. The design capacity of __________ tons or cubic-yards
				  (circle one) per day of nonhazardous ash being disposed of shall not be
				  exceeded.
f. The facility has a total operating area of
				  ____________________ acres.
g. The maximum quantity of nonhazardous ash that can be
				  received per any operating day is _____ tons or cubic yards (circle
				  one).
h. The days and hours of operation shall
				  be______________________________. For facilities with continuous operations,
				  indicate the start of the operating day for purpose of calculating amount of
				  nonhazardous ash received per day.
i. Additional clarifying information concerning the design
				  and operation of the nonhazardous ash facility shall be furnished upon written
				  request of the enforcement agency or the CIWMB.
j. Unless specifically permitted or allowed under Title 14,
				  Division 7, Chapter 3, Article 5.8 of the California Code of Regulations, the
				  facility shall only accept nonhazardous ash.
k. Migration of wastes, leachate, or dust off-site are
				  prohibited.
l. The facility, if located outside of a city, shall be
				  maintained in compliance with the flammable clearance provisions, pursuant to
				  Public Resources Code Section
				  44151.
___________________________
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Toll Free 1-866-896-0600 /
www.calrecycle.ca.gov/Tires/
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State of California
Integrated Waste Management Board
CIWMB-643
						  (NEW 4/2002)
Clean Up Plan
General Information:
(please print or
				  type)
___________________________
Site Name:
___________________________
Address:
___________________________
Phone:
___________________________
Site Operator Name:
Employee in Charge of
Operations on Site:
___________________________
Mailing Address:
___________________________
Phone:
___________________________
Property Owner Name:
___________________________
Mailing Address:
___________________________
Phone:
___________________________
PART A
The operator shall attach to this form a written cost
				  estimate in accordance with Part C, in current dollars, of the cost of hiring a
				  third party to clean up the site. Parts B and C shall be based on the maximum
				  quantity of debris to be stored on site.
PART B
The operator shall provide the following information to the
				  board prior to the commencement of the clean up:
1. A clean up schedule with a time period for
				  completion
2. Details of the final disposition of the debris. Include
				  the name of each business that will receive the debris and the amounts. Provide
				  also the address and phone number for each business.
PART C
CLEAN UP COST ESTIMATE WORKSHEET
The estimate shall be completed by the operator or duly
				  recognized representative to include the following information:
1) The name, address, and telephone number of the site where
				  the debris will be taken.
2) The cost estimate for a third party to cleanup the site
				  along with the detail of how this estimate was calculated, as described below.
				  The estimate shall be developed for the activities anticipated for the clean up
				  including disposition of the debris, equipment, labor and administration.
				  Attach the cost estimate and all supporting documentation used in arriving at
				  the clean up cost estimate.
Calculate the Total Clean Up Cost Estimate in dollars for the
				  operation or facility being cleaned up using the following formula:
Total Clean Up Cost Estimate (TCUC) = 1.2 x (Transportation
				  Cost + Destination Charge + Loading Cost + Administration Cost + Security
				  Cost)
Where:
"Transportation Cost" represents the total cost of
				  transportation for all loads of debris leaving the site as well as the cost of
				  the vehicles returning. The transportation cost shall be computed using the
				  following formula:
Transportation Cost ($) = M x MT x TC
Factor "M" (miles) represents the total distance (Round Trip
				  Mileage) to be covered by a vehicle transporting a load, from the site being
				  cleaned to a facility selected by the operator that would accept the debris in
				  the form that they are, or will be stored.
Factor "MT" (number of round trips) represents the number of
				  truck loads of debris that will be required during the cleanup. The number of
				  truck loads for a particular clean up is determined by dividing the total
				  tonnage of debris by the tonnage of debris that can fit into one truck load.
				  "MT" should be based on the maximum number of loads that will be necessary to
				  clear the site.
Factor "TC" ($ per load per mile) represents the cost per
				  mile to transport a load of debris. The cost includes the average expenses for
				  transportation equipment, fuel, driver wages, tolls, and the vehicles
				  maintenance. This cost will vary based on the size of vehicle.
The "Destination Charge" represents the total cost of tipping
				  fees or disposal fees for all loads of debris transferred from the cleanup site
				  to the destination facility. The Destination Charge shall be computed using the
				  following formula:
Destination Charge ($) = MT x TF
Factor "MT" is described above.
Factor "TF" ($ per load) represents the cost to deposit the
				  debris at the destination facility. This may be a tipping fee or a disposal
				  fee. If the fee is expressed in dollars per ton then this number must be
				  multiplied by the weight of the load in order to yield dollars per load.
"Loading Cost" represents the total cost of loading all loads
				  of debris in to vehicles at the site and unloading the vehicles at the final
				  destination. "Loading Cost" shall be computed using the following
				  formula:
Loading Cost ($) = MT x LC
Factor "MT" is described above.
Factor "LC" ($ per load) represents the unit cost to load one
				  vehicle with debris at the clean up site, and to unload the same debris at the
				  final destination. This cost includes operational expenses which cover wages
				  for workers and pro rated expenses for rental or lease of equipment and
				  machinery.
"Administration Cost" ($) represents the total cost of
				  administration activities for the entire clean up. This cost shall include the
				  wages for personnel overseeing the cleanup activities and other operating
				  expenses for the entire project.
"Security Cost" ($) represents the total cost of security
				  arrangements for entire clean up operation. This is the cost to secure the site
				  and restrict public access. This cost covers the expenses for the entire
				  cleanup operation and includes installations of site fence, installations or
				  repair of lighting, and wages for security guards, etc.
Note:
1) All costs will be added and then
						  multiplied by the contingency factor of 1.2 to estimate Total Clean Up
						  Costs.
2) Any deviations from the above formula must
						  be explained.
3) Complete a separate clean up cost estimate
						  worksheet if the debris is to be transported to more than one point of
						  destination.
OPERATOR CERTIFICATION
Operator certification: I certify that this document and all
				  attachments were prepared under my direction or supervision. I have inquired of
				  the person or persons who manage the system or those persons directly
				  responsible for gathering the information, and certify that the information
				  submitted is, to the best of my knowledge and belief, true, accurate and
				  complete.
___________________________
Operator Signature
Date
State of California
Department of Resources
						  Recycling and Recovery
CalRecycle 682 (Rev. 1/08)
(CalRecycle)
NOTIFICATION OF USE OF TEMPORARY REGISTRATION
				  CERTIFICATE
As the Registered Waste Tire Hauler, you are required to
				  notify the Department of Resources Recycling and Recovery (CalRecycle),
in writing,
within two (2) calendar days of using your Registered
				  Waste Tire Hauler
Temporary Registration Certificate.
To
				  obtain a
Temporary Registration Certificate,
you must check
				  the box on the last page of the "Waste Tire Hauler Registration Application",
				  CalRecycle 60, before submitting the application to the Department.
Please complete the following information and
				  mail or fax this form to the address or fax number listed
				  below.
Notification Date: __________
CalRecycle Tire Program Identification
						  (TPID):
Inoperable Vehicle License Plate #(if
						  applicable): Hauler's Company Name:
Inoperable Vehicle Assigned Decal #(if
						  applicable):
Time Period Of Temporary Registration Use
						  (exact dates):
Temporary Vehicle License Plate #:
(State)
Make/Model Of Temporary Vehicle:
Reason For Temporary Use:
Failure to abide by the requirements of Section
				  18456.4, Temporary Registration of
				  Alternate Vehicles may result in penalties up to $2500 per violation and/or
				  revocation of the Temporary Registration Certificate.
___________________________
___________________________
Signature of Authorized Agent
Date
___________________________
Printed Name of Authorized Agent
Return completed form to:
Department of Resources Recycling and Recovery (Cal
				  Recycle)
Tire Hauler Compliance Section
P.O. Box 4025
Sacramento, California 95812
FAX (916) 319-7605
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NOTE: New information necessary to update the contents of
				  this form, other than the designated agency or its jurisdiction, may be
				  provided in letter format. Local governing body signature is not required for
				  minor change(s).
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