WASTE TIRE SITE NOTIFICATION (TP 1)
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A Waste Tire Site is a place where 1,000 or more waste tires are
store outdoors. Do you own or operate a Waste Tire Site?
Yes
No
(If Yes, complete entire form. If No, complete Item #4 below only.)
Pursuant to Regulation 14, W aste Tire Program, the owner or operator of any waste tire site shall submit the
following to the Department:
1. Site Information
Site Name:
County:
Location:
Latitude:
City/State/Zip:
Property Size
in Dimensions:
Waste Tire Pile
Dimensions:
Section, Township
and Range
Site Directions
from Major
Intersection:
Longitude:
Length:
Width:
Height:
Nbr. of Waste Tires Based Upon actual quantity or 10 Tires Per Cubic Yard:
2. Operator Information
Name of Site
Operator:
Operator Address:
Operator Name:
Operator
Telephone Nbr.:
City/State/Zip:
E-Mail:
3. Owner Information
Name of Property
Owner:
Contact:
Mailing Address:
Fax Nbr.:
City/State/Zip:
Telephone Nbr.:
E-Mail:
4. Certification
To the best of my knowledge, I certify the above information provided is true and correct.
Signature of Authorized Agent
Form TP1
Authority: A.C.A 8-9-403
Page 1 of 1
Rev. 09-11-2012
Print Authorized Agent Name and Title
Date
Attached Waste Tire Abatement Plan and Return Completed Form to:
ADEQ SWMD – Waste Tire Program
5301 Northshore Drive – North Little Rock, AR 72118
Phone: (501) 682-0591 or (501) 682-0585
Fax (501) 682-0611 www@adeq.state.ar.us