Free 53898.pdf - Indiana

ANNUAL W ASTE TIRE REPORT: W ASTE TIRE TRANSPORTER
S tate Form 53898 (1-09) Indiana D epartm ent of Environm ental Managem ent

INSTRUCTIONS:

1. Waste tire transporters must use this form to report the number of waste tires transported during the previous calendar year as required by IC 13-20-14-5(f)(3) and 329 IAC 15-4-14. 2. Print or type all requested information. 3. When completed, return this form to the following address by January 31, of the year following the year reported: IDEM Office of Land Quality, Solid Waste Permits Section, 100 North Senate Avenue, Indianapolis, IN 46204-2251 4. For more information, contact the Solid Waste Permits Section at (317) 232-0066.

Calendar year reported (January 1 through December 31): Transporter Information:
Registration Number Name Address (number and street) City Contact Person State Telephone

20____

IN
(

Zip Code

)

Number of waste tires transported during the reporting year: Passenger Truck

Oversize

Other

Unit of measure used: Preparer:

G whole tires

G tons

G cubic yards

I certify, under penalty of perjury as provided in IC 35-44-2-1, that to the best of my knowledge this information is true and accurate, and that I am an authorized agent of the registrant.

Nam e

Signature

Date (month, day, year)