Adem Form 539 – Fill Out and Use This PDF

Alabama Department of Environmental Management

Scrap Tire Quarterly Report

Facility Name:

Address:

City/State/Zip Code:

County: _____________________________________ Telephone:

Permit or Registration Number: #S

Reporting Period (check one): __Jan Feb Mar; __Apr May Jun; __Jul Aug Sep; __Oct Nov Dec Year

Summary of Tire Materials Handled: All information must be entered completely.

a.Receivers

(1)	Number or tons offered for transportation	Number of tires _______	or	Number of Tons ______
(2)	Number or tons transported to a processor	Number of tires _______	or	Number of Tons ______
(3)	Number or tons transported to a landfill	Number of tires _______	or	Number of Tons ______
b. Transporters
(1)	Number or tons transported to a processor	Number of tires _______	or	Number of Tons ______
(2)	Number or tons transported to a landfill	Number of tires _______	or	Number of Tons ______

c.Processors receiving tire materials

(1)	Number or tons received from transporters	Number of tires _______	or	Number of Tons ______
(2)	Number or tons received from individuals	Number of tires _______	or	Number of Tons ______
(3)	Number or tons received from nonprofits	Number of tires _______	or	Number of Tons ______
d. Processors shipping tire materials
(1)	Number or tons offered for transportation	Number of tires _______	or	Number of Tons ______
(2)	Number or tons transported to a landfill	Number of tires _______	or	Number of Tons ______

e.Solid Waste Disposal Facilities

(1)	Number or tons received from transporters	Number of tires _______	or	Number of Tons ______
(2)	Number or tons received from individuals	Number of tires _______	or	Number of Tons ______
(3)	Number or tons received from nonprofits	Number of tires _______	or	Number of Tons ______

Name, Location and Scrap Tire Permit or Registration Number of transporters, processors and SWDF to whom tire materials were sent. Complete and attach other copies of this form to report all activities, if necessary.

Name		Location (city/state)		Permit/Reg Number

I hereby certify that this report has been examined by me, and to the best of my knowledge and belief, is a true and complete report for the period stated.

signature		date signed
printed name		title

Submit form to: ADEM Solid Waste Branch, PO Box 301463, Montgomery, AL 36130-1463 or via e-mail to TireMail@adem.alabama.gov.

ADEM Form 539 Revised 07/19 m5

INSTRUCTIONS

Scrap Tire Quarterly Report

Complete the name, address, and the telephone number of the facility submitting the quarterly report. Enter the permit number or registration number.

Check the reporting period and indicate reporting period year.

Report the amount of tire materials handled.

Report the name, principal business location (city and state only) and permit or registration number of transporters, processors and SWDF to whom tire materials were sent. Complete and attach other copies of this form to report all activities.

Copies of manifests are NOT to be submitted with quarterly reports, but should be maintained in the operating record.

Print the name and title of the responsible official signing the quarterly report, and the date signed.

This report must be submitted no later than the twenty-eighth day of the next month after the end of the reporting period. Submittal ending dates are as follows: January 28, April 28, July 28, and October 28. Submit this report in paper form or electronically to:

ADEM

Solid Waste Branch

Materials Management Section

(mailing address)	(physical address)
PO Box 301463	1400 Coliseum Blvd
Montgomery, AL 36130-1463	Montgomery, AL 36110-2059

An electronic version of this report may be submitted to ADEM at TIREMAIL@ADEM.alabama.gov. Contact ADEM at 334-271-7988 for additional information about this report form.

Regulations in ADEM Admin. Code 335 may be found on the ADEM web site at: adem.alabama.gov/alEnviroRegLaws/default.cnt. Scrap tire regulations are in Division 4.

ADEM Form 539 Revised 07/19 m5