ANNUAL TIRE SUMMARY: WASTE TIRE STORAGE SITE / WASTE TIRE PROCESSING OPERATION State Form 52716 (R2 / 10-11) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT INSTRUCTIONS: 1. Use this form to report the amount of waste tires managed by a registered Waste Tire Storage or Waste Tire Processing Operation as required by IC 13-20-13-5 (1) and 329 IAC 15-3-20 (b). 2. Print or type all requested information. 3. Use the same unit of measurement for all amounts reported. Conversion factors can be found on page 2 of this form. st 4. This form is due no later than January 31 of the year following the year being reported. 5. When completed, return this form to: Indiana Department of Environmental Management Solid Waste Permits Section IGCN 1101 100 N. Senate Avenue – MC 65-45 Indianapolis, IN 46204-2251 6. For more information, contact IDEM’s Office of Land Quality, Solid Waste Permits Section, at (317) 232-4473. Calendar year reported (January 1 through December 31): 20 Registration Information: Waste Tire Processing Registration Number (if applicable): Waste Tire Storage Site Registration Number (if applicable): Business Information Business Name: Owner Full Name: Business Street Address: City: State: Mailing Address (if different): City: State: Day telephone: ( ) Email Address: ZIP: ZIP: Evening telephone: ( County: ) - Evening telephone: ( Business Contact Name (if different): Day telephone: ( ) Email Address: Units of measure used in this report (check one): County: ) Cubic Yards Tons - Passenger Tire Equivalents (PTE) Amount of waste tires received at this facility during the reporting year: Amount of waste tires disposed of during the reporting year: • Landfill – solid waste • Landfill – alternative daily cover • Civil engineering • Tire derived fuel (TDF) • Reuse (without further processing) • Reuse (with processing) • Other - Specify: Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Total amount of waste tires disposed of (using all disposal methods) Amount of waste tires remaining on-site as of December 31st of the reporting year: Preparer: 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. Name (Print) Signature Date (month, day year) Conversion Factors: Average weight of one whole passenger tire = 20 lbs = 1 PTE (Passenger Tire Equivalent) Average weight of one whole semi-truck tire = 100 lbs = 5 PTEs 100 passenger tires = 1 ton (2,000 lbs) 20 semi-truck tires = 1 ton (2,000 lbs) 10 PTEs/yd3 3 semi-truck tires/yd3 27-30 PTEs/yd3 42-47 PTEs/yd3 Whole passenger tires Whole “semi” truck tires Single pass/rough shreds 2-inch shreds APPROXIMATE NUMBER OF WHOLE PTEs IN EACH PILE PILE SIZE 10 FT 11 FT 12 FT 13 FT 14 FT (in feet) HIGH HIGH HIGH HIGH HIGH 50’ X 50’ 100’ X 50’ 100’ X 100’ 150’ X 100’ 200’ X 200’ 1 ACRE 2 ACRE 3 ACRE Note: 1. 2. 3. 9,259 18,519 37,037 55,556 148,148 161,333 322,667 484,000 10,185 20,370 40,741 61,111 162,963 177,467 354,933 532,400 11,111 22,222 44,444 66,667 177,778 193,600 387,200 580,800 12,037 24,074 48,148 72,222 192,593 209,733 419,467 629,200 12,963 25,926 51,852 77,778 207,407 225,867 451.733 677,600 20 FT HIGH 18,519 37,037 74,074 111,111 296,296 322,667 645,333 968,000 200 lbs/yd3 300 lbs/yd3 550-600 lbs/yd3 850-950 lbs/yd3 CONSTANT for one foot height increase or decrease 926 1,852 3,704 5,555 14,815 16,133 32,267 48,400 The above table is based on 10 whole PTEs/yd3 and 43,560 square feet per acre. Compaction will influence the total. Compaction is influenced by overall height of pile and length of storage time in pile. Be advised Fire Marshall Codes (675 IAC 22-2.4) prohibit tire piles greater than 5,000 square feet in continuous area, 50,000 cubic feet in volume, or 10 feet in height. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com