Appendix A Forms
14 CA ADC Div. 7 Ch. 9 App. A FormsBarclays Official California Code of Regulations
14 CCR Div. 7 Ch. 9 App. A Forms
Appendix A Forms
CIWMB Form Number 36 (rev. 11/94)
State of California
Oil Recycling Program
Fee Exemption CertificateName 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
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:
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Individual Sole Proprietorship Limited Liability Company Corporation Political SubdivisionStreet
City
__________________________________________________
State
_________________________
Zip Code
4. Business Owner: (Individual, CEO, President, Managing Partner(s)):
__________
/ Phone Number
Social Security Number
__________
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__________
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__________
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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
Yes or No if yes, please explain.
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.
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.
For example, a shipment may contain 100 whole tires and/or 100 pounds of processed tires.
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 Requirements
December 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) |
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.
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
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) |
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.
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.
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
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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:
PART C
CLEAN UP COST ESTIMATE WORKSHEET
The estimate shall be completed by the operator or duly recognized representative to include the following information:
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): |
Hauler's Company Name: |
Inoperable Vehicle License Plate #(if applicable): |
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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This database is current through 4/12/24 Register 2024, No. 15.
Cal. Admin. Code tit. 14, Div. 7 Ch. 9 App. A Forms, 14 CA ADC Div. 7 Ch. 9 App. A Forms
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