Form DEP 7101D-1 (11/08)

ENERGY AND ENVIRONMENT CABINET

DEPARTMENT FOR ENVIRONMENTAL PROTECTION

DIVISION OF WASTE MANAGEMENT

200 FAIR OAKSLANE, 2ND FLOOR

FRANKFORT, KY40601

TELEPHONE NUMBER (502) 564-6716

Performance Agreement for Waste Tire Registrants
DEP Form 7101-D (05/09)

Registration Number:

Facility Name:

Facility Address:

Facility Owner:

Owner Address:

Type of Financial Assurance:

_____Surety Bond (# )

Irrevocable Letter of Credit (# )

Trust Fund Agreement (#)

Certificate of Insurance (#)

Corporate Guarantee (# )

Form DEP 7101D-1 (11/08)

KNOW ALL PERSONS BY THESE PRESENTS, that the undersigned, , as Principal (Registrant), is held and firmly bound unto the Energy and Environment Cabinet in the penal sum of dollars ($) which sum is herewith deposited by the submission of the financial assurance mechanism(s) identified above. The Principal posts this/these financial assurance mechanism(s) by and through its agent(s) as a guarantee that the provisions of the registration issued pursuant to Registration Number , all applicable laws, rules, and regulations will be observed and hereby bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents. This bond is effective upon receipt by the Division of Waste Management (hereinafter Division).

THE CONDITION OF THE ABOVE OBLIGATION IS SUCH, that, whereas, the above bound Principal, pursuant to the provisions of KRS Chapter 224 and the regulations promulgated pursuant thereto did file with the Division, a registration to operate as a waste tire processor or accumulator in the Commonwealth of Kentucky; that in said application the Principal identified the area to be registered as acres, located in County, at or near the community of ; and whereas the above described area will be affected by the facility during the life of the registration and until the Principal has completed proper closure and corrective action (if required), and the Cabinet has certified the same. Furthermore, it is understood that the obligation under this bond extends to any environmental degradation occurring from the waste tire operation.

Form DEP 7101D-1 (11/08)

Now, if said , as Principal, shall faithfully perform all the requirements of the above designated and the applicable laws, rules, and regulations, and the terms of this bond, then this obligation shall be released; otherwise, it is agreed that said penal sum shall be paid to the Commonwealth of Kentucky, Energy and Environment Cabinet Demand Letter.

“I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for such violations.”

Name of Person Signing (type or print):

Title of Person Signing: Date: - -

Signature per 401 KAR 47:160: ______

Subscribed and sworn to before me this ______day of ______, Year 20_____

Notary Public Signature: ______

State of _____County of ______My commission expires: ______