DSHW-2018-003226 - 0901a068807e9395

Div of Waste Management
and Radiation Control
APR 6 2016 Waste Tire Transporter
Registration Application -Ar c200,tfie
Wittig Adchess Office Location „notr1) 536-0222 ffiiM S4 0241 It" I 1g gr- P 0.130x 144880 195 NI n-th 1950 West Fax ( 0 Salt Lake City, Utah 84114-4380 Salt 1 ake City. Utah 84116 www.desi
UTAH DEPARTMENT of
ENVIRONMENTAL QUALITY
WASTE MANAGEMENT
RADIATION CONTROL.
Pursuant to Utah Administrative Code R315-320-4, to obtain a waste tire transporter registration number and approval 6)
to act as a waste tire transporter, a transporter shall submit the followin information, using this form,vith required ÍCJrT
documentation to the Division of Solid and Hazardous Waste. -
paid r utaltt
Part 1 Site Inforimat op - APPLICANT: PLEASECOMPLETE ALL SECTIÑS.'
A. Application,Type X4 Proposed new facility fl Renewal of registration Current registration number
Other, please explain fl Modification of registration Current registration number
B. Transporter tläne and Location
Legal Name of Transporter
Transporter Mailing Address
CitY BEAR RIVER CITY
REVOLUTION TIRE RECYCLING, LLC
P.O. BOX 294
State UT ZIP Code 84301 Phone Number 8016949515
Site Address (street or directions
City BEAR RIVER
to site) 7500 N HWY 13, (TAKE EXIT 376 OFF1-15, HEAD SOUTH APPROX 3 MILES, ON EAST SIDE OF RD.
ZIP Code 84301 Phone Number 8016949515
C. i information
Other Business Names of Transporter (DBA's) NONE
D. Contact Inforinailon
Contact Name MICHAEL ) ADAMS Title OPERATIONS MANAGER
Address 7500 N HWY 13
City BEAR RIVER CITY State UT Zip Code 84301 Phone Number 2084310931
Email [e-mail] Alternative Phone Number
Part 11 G'e' here Inf rmation _
A. TIre Disposal List all knownsites where )(Oil wilt be depos1tn9 waste tiree fo proesslng, disposal or recyciing (attach addltlonatstteets i No* Utah Code Annotated 10-0,804bans theclteposal tif wtccM tires, diet ariaregulated by the Wasta Tire FtecydIng Ackal landfis lithe disposal is by a waste th;a transpotter. Recynfers lsluuttuelšgtetered . , . with thalslon and storage efteentust have! permltftomthe divislom ,' .
Name Address County
MAIN PLANT 7500 N HWY 13, BEAR RIVER CITY, UT 84103 BOX ELDER
B. Fee and Other btiO: ems
.
Is Transporter Currently Registered with a Local Health
Liability Amount 3.000.000/1.000.000 Policy Issuer
Department
an annual registration
Of Yes Yes and fee paid) attach registration No (If No include $100 Registration Fee)

Name MERIDIAN INSURANCE Expiration Date MARCH 29,2019
Registration Fee: The Utah Legislature, in the Annual Appropriation Act, has approved application. Note Utah Administrative Code R315-320-5(7)(b) allows a waiver of the registration fee of $100.00 for registration of a waste tire transporter. The fee must be submitted with this fee for a waste tire transporter that has a valid registrahon from a local health department within Utah.
[HERESY CERTIFY TH T THIS INF R ION AND ALL A ' A HED PAGES,ARE CORRECT AND COMPtETE. r‘
Signature of Authorized
Owner Representative*
Type Name
*Authorized representative
Title GENERAL MANAGER
TERRY R ALAMS
Date APRIL 2, 2018
Address 7500 N HWY 13, BEAR RIVER CITY, UT 84103
is defined by Utah Administrative Code R315-310-2(4)