CONSTRUCTION SITE REPROCESSING FACILITY APPLICATION

Transcription

1 CONSTRUCTION SITE REPROCESSING FACILITY APPLICATION CITY OF CHICAGO DEPARTMENT OF PUBLIC HEALTH AS REQUIRED UNDER THE PROVISIONS OF THE ENVIRONMENTAL PROTECTION AND CONTROL ORDINANCE (CHAPTER 11-4 OF THE MUNICIPAL CODE OF THE CITY OF CHICAGO): In order to receive a temporary rock crushing authorization from the Chicago Department of Public Health (CDPH), this application must be submitted and completed in its entirety. If further space is required, include additional sheets as attachments to this form as needed. Please type or print neatly. Failure to answer all questions properly and completely will result in the rejection of this application. For example, NA for Not Applicable is not a proper response. Type of Permit Requested: Check one: New Permit Extension Check one: 1 month ($750) 2 months ($1,500) 3 months ($2,250) Site Address: Date of Application: Anticipated Start Date: Anticipated End Date: Anticipated Work Days: Authorization shall be valid for no more than three months and all crushing operations shall occur between 8am-5pm. If crushing is not completed within three months, you must apply for an extension. Fee: Enclose a check in the amount of $750 times the number of months for which the authorization is sought, as specified in Section of the Municipal Code Note: In addition to completing this form, you must obtain an Air Pollution Control (APC) permit(s) from CDPH for all reprocessing equipment used on-site as required under Section of the Municipal Code. Please call (312) for information regarding APC permits. 1. Applicant Information: Name Phone Number Address City State Zip Code 2. Property Owner/Developer Information*: Name Phone Number Address City State Zip Code *If the Developer is a partnership or corporation, include as an attachment to this form the names, addresses, phone numbers and social security numbers of all persons holding a share in the partnership or corporation.

2 1. Provide property owner written and signed consent to the reprocessing activity and temporary storage of reprocessed materials. If Title of Property is held in trust, attach to this form the names and addresses of all beneficiaries and other persons authorized to deal with the property. 2. Provide a copy of the courtesy letter and return receipt to the alderman for the ward in which the construction reprocessing operation will be located, setting forth the intention and nature of use. 3. Check the specific types of material to be reprocessed Broken Concrete Bricks Rock Stone Paving Asphalt 4. Estimate of the total quantity of material to be reprocessed and used onsite (in tons): 5. Explain how the total quantity of material to be processed was calculated: 6. Describe: A. The planned end-use for the reprocessed material. Indicate on the site sketch (see #10) where the reprocessed material will be used onsite: B. The planned end use of the subject property once construction and demolition activities are complete: C. Provide the Dept. of Buildings construction or storm water permit # that indicates the planned end use of the subject property: NOTE: Per Section 4.4 of the Construction Site Reprocessing Rules & Regulations, if there is no planned and permitted use of the site, all reprocessed material must be removed within the period of this authorization. 2

3 7. Name and location of all permitted facilities where incidental debris will be disposed of (Note: Section of the Municipal Code of Chicago defines incidental debris as...uncontaminated dirt, metal, mortar, gypsum, plasterboard, wood, and sand which are derived from a construction or demolition site and intermingled with reprocessable material. Such incidental debris must be disposed of at a properly permitted facility. Under no circumstances shall incidental debris be disposed of on-site.) Name: Name: Name: Address: Address: Address: 8. Name and location of all permitted facilities where crushed material not used onsite will be sent: Name: Address: Name: Address: Name: Address: 9. Describe the methods, processes, equipment, etc. that will be used to control: Noise Dust emissions Trackout 10. Provide a complete site sketch or aerial photograph, to scale, indicating property boundaries, locations of the reprocessing equipment, raw material stockpiles, finished product stockpiles, and all water sources. Site plans must be 8 ½ x 11" or 11" x 17" in size only. Blue prints are not acceptable for site plans. (For government-togovernment transfers, provide a second site sketch for the end-use site.) 11. Section (a)(3) of the Municipal Code states that no reprocessing device or stockpile of reprocessable construction/demolition material or of reprocessed construction/demolition material shall be located within 200- feet of any schools, childcare facilities, hospitals, and residential buildings or mixed-occupancy building with a residential use; and within 100 feet from other buildings, public ways, and parks. Indicate the distance and direction to the nearest: School: feet; Direction: Childcare facility: feet; Direction: Hospital: feet; Direction: Residential or mixed occupancy building: feet; Direction: Other building: feet; Direction: Public way: feet; Direction: Park: feet; Direction: 12. If the planned end-use for the reprocessed material does not include qualified adjacent sites, or is a government-to-government transfer, proceed to #14. NOTE: Governmental entities must maintain current and accurate records identifying the date and location of all anticipated and actual transfers of such reprocessed construction/demolition material. 3

4 13. If the planned end-use for the reprocessed material is for adjacent properties, indicate the distance between the demolition site and the construction site on the site sketch and in the planned end-use description (see #6B). Adjacent properties must be owned by the same property owner who owns the demolition site and developed by the same developer or general contractor who is the developer or general contractor at the demolition site. For definitions and additional regulatory requirements regarding the use of processed material on properties adjacent to the demolition site, please refer to the Chicago Department of Public Health (CDPH) regulations entitled Construction Site Reprocessing Rules and Regulations. The regulations can be found on the CDPH website at Certification I certify that I have personally examined and am familiar with all the information submitted in response to the questions contained in this application and the attached document(s), and that based on my inquiry of those individuals immediately responsible for obtaining the information. I believe that all information submitted is true, accurate and complete. I also certify that only materials generated from Site demolition activities will be reprocessed at the Site and such reprocessed materials will be used only at the Site (or pursuant to an approved government-to-government transfer). Name: Title: Company Name: Mailing Address: Phone Number: Fax Number: address: Signature: Rev. 07/22/13 4

5 CONSTRUCTION SITE REPROCESSING FACILITY SITE SKETCH Name of Facility: Address: City, State, Zip Code: Owner/Operator: 5

6 POS INVOICE Reference Number: Qty Description Unit Price TOTAL Public Health (041) TEMPORARY ROCK CRUSHER PERMIT FEE $ - $ - $ -. TOTAL $ - Remit to: City of Chicago City Hall Cashier Window 121 N. LaSalle Rm. 107 Chicago, IL Point of Sale