WASTE TIRE TRANSPORTER
LICENSE APPLICATION (TP-2)
Pursuant to Regulation 14, Waste Tire Program, to obtain a W aste Tire Transporter License to transport used tires,
waste tires, and processed tires, a transporter is required to provide the following information to the Department:
1. Vehicle Information (For fleet attach additional sheets.)
Date:
Complete the following for each vehicle to be licensed.
Year
Model
License Plate Nbr.
Vehicle Identification Nbr.
Name of Registered Vehicle Owner:
2. Transporter Information
Owner
Manager
Business Name of
Transporter:
above
Person
Completing Form
Telephone Nbr.:
Site Location:
Fax Nbr.:
Site City/State/Zip:
County:
Mailing Address:
E-Mail:
Other Business
Names (DBA):
same as above
City/State/Zip:
Counties to be
Served:
Do you own or operate a Waste Tire Site? A Waste Tire Site is a place where 1,000 or more
waste tires are store outdoors. (If yes, complete and submit a TP1 Waste Tire Site Notification Form.)
Are you registered to transport tires in another state:
Yes
No
Yes
No
If yes, list name of state and license/registration/permit Nbr.:
If you are a common carrier for hire transporting tires list the
Public Service Commission (PSC) authority Nbr.:
Federal Employer Tax ID Nbr. or Social Security Nbr.:
3. Enforcement Information (attach additional sheets as needed)
Have there been any civil and/or criminal legal actions against the applicant by government agencies involving
environmental protection laws or regulations in the 10 years immediately preceding the filing of this application?
Have there been any administrative enforcement actions resulting in the imposition of sanctions?
Has there been any permit or license revocations or denials issued by any state or federal authority?
Have there been any actions that have resulted in a finding or settlement of a violation?
Are there any actions that are currently pending?
If you answered “Yes” to any of the questions above, please explain:
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
4. Required Attachments




Copy of proof of liability insurance
Copy of Drivers License(s)
Check or money order in payment of fees
Disclosure Statement
Form TP2
Authority: A.C.A 8-9-403
Page 1 of 2
Rev 9-6-2012
Please check applicable box:
NEW FLEET :
$ 250.00 ; or
NEW VEHICLE:
_#
_
x $35.00 each = $
Return Completed Form and Attachment(s) 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
5. Businesses Where Tires will be Collected (attach additional sheets as needed)
Name
Address
Telephone
Type of Tire
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
Used
Waste
Processed
6. Businesses Where Tires will be Transported and Deposited (attach additional sheets as needed)
Name
Address
Telephone
Disposition
Retread
Resale
Retread
Resale
Retread
Resale
Retread
Resale
Retread
Resale
Retread
Resale
Retread
Resale
Retread
Resale
1.
2.
3.
4.
5.
6.
7.
8.
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recycling
Processing
Recap
Disposal
Recap
Disposal
Recap
Disposal
Recap
Disposal
Recap
Disposal
Recap
Disposal
Recap
Disposal
Recap
Disposal
7. Certification
To the best of my knowledge, I certif y the above information provided is true and correct.
Signature of Authorized Agent
Form TP2
Authority: A.C.A 8-9-403
Page 2 of 2
Rev 9-6-2012
Print Authorized Agent Name and Title
Date
Return Completed Form and Attachment(s) 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