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WASTE TIRE COLLECTION CENTER

ANNUAL REPORT

Pursuant of Regulation 14, Waste Tire Program, Waste Tire Collection Centers are required to submit the following information to the Department through their respective solid waste regional management board by March 1 of each year.

1. Permit Information

AFIN:

Permit Nbr.:

RSWMD:

Waste Tire District:

- SG-WTX

2. Site Information (One Annual Report per Collection Center)

Collection Center Name:

Physical Location:

City/State/Zip:

Phone:

3. Facility Mailing Address

Name:

Mailing Address:

City/State/Zip

Phone / Fax Nbr.: /

Calendar Year Covered By Report:

County:

Latitude:

Longitude:

Operator Name:

4. Quantities of Waste Tires Managed During the Calendar Year Reported a. Quantity of waste tires located at the facility on January 1: b. Quantity of waste tires received during this reporting period: c. Quantity of waste tires shipped for recycling or disposal during this reporting period: d. Quantity of waste tires located at the facility on December 31:

5. Sites where waste tires or processed tires were shipped for disposal or recycling

Name Address Telephone

6. Certification

To the best of my knowledge, I certify the above information provided is true and correct.

Signature of Authorized Agent Print Authorized Agent Name and Title

Total

Nbr. of Tires

Date

Form TP8

Authority:A.C.A 8-9-403

Page 1 of 1

Rev. 09-25-2012

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

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