DSHW-2025-000446

PART I - GENERAL INFORMATION APPLICANT: PLEASE COMPLETE ALL SECTIONS
I. Application Type New Application Major Modification (see R315-311-2(1)(c)) Renewal Application Minor Modification (see R315-311-2(1)(a))
For Renewal Applications, Facility Expansion Applications, and Modifications Applications, enter current permit number:
.
II. Facility Name and Location
Legal Name of Facility
Facility Address (Street or Directions to Facility)
County
City
Zip Code
Telephone
Township
Range
Section
Quarter Section
Quarter/Quarter SectionMain GateLatitude:Longitude:
III. Facility Owner(s) Information
Name of Facility Owner
Mailing Address
City
State
Zip Code
Telephone
IV. Facility Operator(s) Information
Name of Facility Operator
Mailing Address
Click or tap here to enter text.
City
State
Zip Code
Telephone
V. Property Owner(s) Information
Name of Property Owner
Mailing Address
City
State
Zip Code
Telephone
VI. Designated Contact Information
Facility Owner Designated Contact (if different than above)
Title
Mailing Address
City
State
Zip Code
Telephone
Email Address
Alternative Telephone (cell phone or other)
Facility Operator Designated Contact (if different than above)
Title
Mailing Address
City
State
Zip Code
Telephone
Email Address
Alternative Telephone (cell phone or other)
Property Owner Contact (if different than above)
Title

Mailing Address
City
State
Zip Code
Telephone
Email Address
Alternative Telephone (cell phone or other)
VII. Waste Types (check all that apply)
VIII. Facility Area
Whole waste tires
Material derived from waste tires
Other:
Facility Area: acres
Recycle Area: acres
PART II - APPLICATION CHECKLIST
Description of Item
Rule(s) Cited
Included in Submission
Location in the Document/Comments
Ia. Requirements for All Facilities
Complete Part I - General Information
R315-310-3(1)(a)
Yes No, explain
General facility descriptions including maps, plans, and drawings
R315-310-3(1)(b)
Yes No, explain
Legal description of the property, proof of ownership, lease agreement, or other mechanism
R315-310-3(1)(c)
Yes No, explain
The Plan of Operation as required by R315-302-2(2)
R315-310-3(1)(e)
Yes No, explain
Form used to record weights or volumes of wastes received required by R315-302-2(3)(a)(i)
R315-310-3(1)(f)
Yes No, explain
Inspection schedule and inspection log as required by R315-302-2(5)(a)
R315-310-3(1)(g)
Yes No, explain
Closure and post-closure care plans
R315-310-3(1)(h)
Yes No, explain
Proposed financial assurance plan that meets the requirements of R315-309
R315-310-3(1)(j)
Yes No, explain
Historical and archeological identification efforts
R315-310-3(1)(k)
Yes No, explain
For a new facility owned or operated by a local government, financial information that discloses the costs of establishing and operating the facility
R315-310-3(1)(l)
Yes No, explain
Ib. Public Participation Requirements
Name and address of all owners of the property within 1,000 feet of the proposed facility
R315-310-3(2)(a)(i)
Yes No, explain
Documentation that a notice of intent to apply for a permit for a solid waste facility has been sent to all property owners identified in R315-310-3(2)(a)(i)
R315-310-3(2)(a)(ii)
Yes No, explain
Name of the local government with jurisdiction over the site and the mailing address of that local government office
R315-310-3(2)(a)(iii)
Yes No, explain

II. Location Standards for Waste Tire Storage Facilities
Historic preservation survey
R315-302-1(2)(f)
Yes No, explain
A traffic impact study approved by the jurisdictional authority of the roads serving the facility that:
Demonstrates requirements for safety, operation, and condition of roadways will meet forecasted needs; and
Includes any improvement and maintenance agreements with the road authority.
R315-302-1(2)(g)
Yes No, explain
IIIa. Plan of Operation for All Facilities
An intended schedule of construction
R315-302-2(2)(a)
Yes No, explain
Description of on-site solid waste handling procedures
R315-302-2(2)(b)
Yes No, explain
Schedule for conducting inspections and monitoring
R315-302-2(2)(c)
Yes No, explain
Contingency plans in the event of a fire or explosion
R315-302-2(2)(d)
Yes No, explain
Corrective action programs to be initiated if groundwater is contaminated
R315-302-2(2)(e)
Yes No, explain
Contingency plans for other releases, for example, release of explosive gases or failure of run-off containment system
R315-302-2(2)(f)
Yes No, explain
Plan to control fugitive dust
R315-302-2(2)(g)
Yes No, explain
Plan to control wind-blown litter
R315-302-2(2)(h)
Yes No, explain
Description of maintenance of installed equipment including leachate and gas collection systems, and groundwater monitoring systems
R315-302-2(2)(i)
Yes No, explain
Procedures for excluding the receipt of prohibited hazardous waste or prohibited waste containing PCBs
R315-302-2(2)(j)
Yes No, explain
Procedures for controlling disease vectors
R315-302-2(2)(k)
Yes No, explain
Plan for an alternative waste handling or disposal system during periods when the solid waste facility is not able to dispose of solid waste, including procedures to be followed in case
of equipment breakdown
R315-302-2(2)(l)
Yes No, explain
Closure and post-closure care plans
R315-302-2(2)(m)
Yes No, explain
Cost estimates and financial assurance information as required by R315-309-2(3)
R315-302-2(2)(n)
Yes No, explain
Training plan for site operations
R315-302-2(2)(o)
Yes No, explain
IIIb. Other Site-Specific Information Pertaining to the Plan of Operation as Required by the Director
A plot plan of the storage site showing the arrangement and size of the tire piles on the site, the width of fire lanes and the type and location of the fire control equipment and the
location of any on-site buildings and the type of fencing to surround the site
R315-314-3(3)(a)(iii)(A) through (C)

Yes No, explain
Documentation to show tires are only being accumulated in designated areas
R315-314-3(3)(b)
Yes No, explain
Documentation demonstrating controlled access to the storage site by fencing
R315-314-3(3)(c)
Yes No, explain
Plan on how the facility will limit individual tire piles to a maximum of 5,000 square feet of continuous area in size at the base of the pile
R315-314-3(3)(d)
Yes No, explain
Plan on how the facility will limit the individual tire piles to 50,000 cubic feet in volume or ten feet in height
R315-314-3(3)(e)
Yes No, explain
Plan on how the facility will ensure piles will be at least ten feet from any property line or any building and not exceed size feet in height if within 20 feet from any property line
or building
R315-314-3(3)(f)
Yes No, explain
Documentation showing the facility will provide a 40-foot fire lane between tire piles that contains no flammable or combustible material or vegetation
R315-314-3(3)(g)
Yes No, explain
A vector control program to minimize mosquito breeding and the harborage of other vectors such as rats or other animals
R315-314-3(3)(h)
R315-314-3(3)(a)(v)
Yes No, explain
Documentation demonstrating the facility will provide on-site fire control equipment that is maintained in good working order
R315-314-3(3)(i)
Yes No, explain
Display of an emergency procedures plan and inspection approval by the local fire department and require each employee to be familiar with the plan
R315-314-3(3)(j)
Yes No, explain
Documentation demonstrating the facility will maintain a record of the number of tires received at the site, tires shipped from the site, piles of tires at the site, and tires in each
pile
R315-314-3(3)(l)
Yes No, explain
Documentation demonstrating the facility will meet the reporting requirements as required by R315-302-2(4)
R315-314-3(3)(m)
Yes No, explain
IV. Closure and Post Closure Care Requirements for Waste Tire Storage Facilities
Closure plan as required by R315-302-3meeting the requirements of R315-312-3(5)(a)
R315-310-3(1)(h)
R315-302-2(2)(m)
Yes No, explain
Post-closure care plan as required by R315-302-3(6) which includes the post-closure care and monitoring to be for five years and include the maintenance of any monitoring equipment and
sampling and testing schedules as required by the Director and the inspection and maintenance of any cover material.
R315-310-3(1)(h)
R315-302-2(2)(m)
R315-312-3(5)(b)
Yes No, explain
V. Financial Assurance Requirements for Waste Tire Storage Facilities
Establish financial assurance for clean up and closure of the site in the amount of $150 per ton of tires stored at the site and in the form of a trust fund, letter of credit, or other
mechanism as approved by the Director
R315-314-3(3)(k)
Yes No, explain
Identification of closure costs including cost calculations as required by R315-309-2(3)(a)
R315-314-3(3)(a)(iv)
Yes No, explain
Identification of post-closure costs including cost calculations as required by R315-309-2(3)(b)
R315-314-3(3)(a)(iv)
Yes No, explain
Identification of a financial assurance mechanism, which will cover the costs of post-closure care, in effect and active as required by R315-309-2(5)

R315-314-3(3)(a)(iv)
Yes No, explain