4119TP-TIRETP-_FAR-FY17-18

Tire T&P 2018 Page 1
Facility Name:Permit:
Physical Address
Street 1:
Street 2:
City:
State:Zip:
County:
Mailing Address
Street 1:
Street 2:
City:
State:Zip:
Primary Facility Contact Person
Name:
Phone:Fax:
Email:
Billing Contact Person
Name:
Phone:Fax:
Email:
1. Tipping Fee: $per Ton (Attach a schedule of tipping fees if appropriate.)
3. Indicate the type of treatments used and the quantity of tires for each treatment. Please indicate whether TONS or NUMBER OF TIRES.
TREATMENT TONS Number of TIRES
Quantity of tires shipped off-site for tire derived fuel (TDF).
Quantity of tires shipped off-site for civil engineering applications.
Quantity of tires shipped off-site for agricultural applications.
Quantity of crumb rubber shipped off-site.
Quantity of tires shipped off-site for other products (Specify):
Quantity of tires shipped off-site for recapping or resale.
5. Indicate the quantity of unprocessed tires stockpiled on-site as of June 30, 2018 (tons)
6. Indicate the quantity of processed tires stockpiled on-site as of June 30, 2018 (tons)
4. If whole tires are exported, list the country(s) where tires are shipped and the number of tons or tires exported to each country. (Attach a
list, if needed).
TIRE
T&P
State of North Carolina
Department of Environmental Quality
Division of Waste Management
TIRE TREATMENT & PROCESSING FACILITY
Facility Annual Report
For the period of July 1, 2017-June 30, 2018
According to G.S. 130A-309.09D(b), completed forms must be returned by August 1, 2018, and a copy of this report must be sent to the
County Manager of each county from which waste was received. If you have questions or require assistance in completing this report, contact
your Regional Environmental Senior Specialist.
2. Did your facility stop receiving waste during this past Fiscal Year? Yes No
If so, please report the date this occurred:
Tire T&P 2018 Page 2
7. Total waste received at this facility during the period of July 1, 2017, through June 30, 2018. Indicate tonnage received by COUNTY of
waste origin. Please indicate COUNTY and STATE, if received from another state.
Received from Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Total
Grand Total
CERTIFICATION: I certify that the information provided is an accurate representation of the activity at this facility.
Signature:Date:
Name:
Phone Number:Email:
8. Indicate the facility(s) that received your facility's non-recycled waste material:
NAME, PERMIT #, and LOCATION (city, state) of FACILITY Tons
TOTAL
Facility Type
Title:
REMINDER: According to G.S. 130A-309.09D(b), this
report must be sent to the Regional Environmental Senior
Specialist for your area and a copy of this report must be
sent to the County Manager of each county from which
waste was received.
Please return your completed report to: