Arkansas Department of Energy and Environment



USED TIRE TRANSPORTER LICENSE FORMCHECKBOX Initial Used Tire Transporter License Application FORMCHECKBOX Renewal Used Tire Transporter License Application FORMCHECKBOX Annual ReportPursuant to APC&EC Regulation 36, to obtain a Tire Transporter License to transport used tires, waste tires, and processed tires, Form TAP-2 must be completed and submitted to the Division:1. Vehicle Information (For fleet attach additional sheets.)Date: FORMTEXT ?????Complete the following for each vehicle to be licensed.a. Yearb. Modelc. License Plate Numberd. Vehicle Identification Number (VIN) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????e. Name of Registered Vehicle Owner: FORMCHECKBOX (Check if same as operator of vehicle) FORMTEXT ?????2. Transporter Informationa.Business Name of Transporter: FORMTEXT ?????f.Owner: FORMTEXT ?????g.Manager: FORMCHECKBOX same as above FORMTEXT ?????h.Person Completing Form: FORMTEXT ?????b.Address: FORMTEXT ?????i.Phone Number: FORMTEXT ?????c.City/State/Zip: FORMTEXT ?????j.Fax Number: FORMTEXT ?????d.Mailing Address: FORMCHECKBOX same as above FORMTEXT ?????k.County: FORMTEXT ?????l.Email Address: FORMTEXT ?????e.City/State/Zip: FORMTEXT ?????m.Other BusinessName (DBA): FORMTEXT ?????n.Counties to be Served: FORMTEXT ?????o.Are you registered to transport tires in another state? FORMCHECKBOX Yes FORMCHECKBOX Nop.If yes, list name of state and license/registration/permit number: FORMTEXT ?????q.If you are a common carrier for hire transporting tires list the Public Service Commission (PSC) authority number: FORMTEXT ?????r.Federal Employer Tax ID Number or Social Security Number: FORMTEXT ?????3. Enforcement Information (attach additional sheets, as needed)a.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? FORMCHECKBOX Yes FORMCHECKBOX Nob.Have there been any administrative enforcement actions resulting in the imposition of sanctions? FORMCHECKBOX Yes FORMCHECKBOX Noc.Have there been any permits or license revocations or denials issued by any state or federal authority? FORMCHECKBOX Yes FORMCHECKBOX Nod.Have there been any actions that have resulted in a finding or settlement of a violation? FORMCHECKBOX Yes FORMCHECKBOX Noe.Are there any actions that are currently pending? FORMCHECKBOX Yes FORMCHECKBOX Nof.If you answered “Yes” to any of the questions above, please explain: FORMTEXT ?????4. Required Attachments FORMCHECKBOX Copy of Proof of Liability Insurance FORMCHECKBOX Copy of Driver’s License(s) FORMCHECKBOX Safety Inspection Completed FORMCHECKBOX Disclosure Statement FORMCHECKBOX Disclosure Statement Attached FORMCHECKBOX Proof of $10,000 Bond; Bond # FORMTEXT ????? FORMCHECKBOX Payment of Fees (check or money order) FORMCHECKBOX Renewal: # FORMTEXT ????? x $50 each = $ FORMTEXT ????? FORMCHECKBOX New Vehicle: # FORMTEXT ????? x $50 each = $ FORMTEXT ?????5. Businesses Where Tires will be Collected (attach additional sheets as needed)NameAddressTelephoneType of Tire1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed9. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed10. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed11. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed12. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed13. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed14. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed15. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed16. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed17. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Used FORMCHECKBOX Waste FORMCHECKBOX Processed6. Businesses Where Tires will be Transported and Deposited (attach additional sheets as needed)NameAddressTelephoneDisposition1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Retread FORMCHECKBOX Resale FORMCHECKBOX Recycling FORMCHECKBOX Processing FORMCHECKBOX Recap FORMCHECKBOX Disposal7. CertificationTo the best of my knowledge, I certify the above information provided is true and correct. FORMTEXT ?????4994694-2642044460-2640-264Signature of Authorized Agent Print/Type Authorized Agent Name and Title Date ................
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