Adem Form 541 – Fill Out and Use This PDF

Alabama Department of Environmental Management

Scrap Tire Site Registration

Form for use in notification of scrap tire sites which contain greater than 100 scrap tires.

Section 1: Names of Property Owners. List all owners of the property. Use additional sheets as necessary.

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Section 2: Location of the Site and Estimated Number of Scrap Tires. Give the address and location description of the scrap tire site. Give a best estimate of the number of scrap tires and the area of the site.

Address:

County:

GPS Coordinates: Latitude __________________________ Longitude __________________________________

Location:

¼,

¼,

Section

Township

Range

and

¼,

¼,

Section

Township

Range

.

Estimated number of tires:

Estimated area of sites:

acres

Section 3: Responsible Party for Placement of Scrap Tires. List the person(s) responsible for placement of scrap tires on this property if known.

Name:

Address:

Telephone:

Name:

Address:

Telephone:

Section 4: Name of Person Submitting Form.

Signature:

Printed Name:

Telephone: ________________

ADEM Form 541 01/10

INSTRUCTIONS

Scrap Tire Site Registration

Section 1: Complete the name and address of all landowners of the property on which scrap tires are present. List all landowners of record; include additional sheets as needed to show all landowners.

Section 2: Give the location of the property where the scrap tire site is located, and the location of the site by section, township and range and/or GPS coordinates. Register one property per form. Estimate the total number of tires that are on the property, and the area of land occupied by the scrap tires.

Section 3: Name the responsible parties who placed the scrap tires on the property. Indicate “UNKNOWN” if the persons responsible for placement of scrap tires are unknown to the property owner.

Section 4: Print the name of the person signing and submitting this form. Submit the form to:

ADEM

Solid Waste Branch

(mailing)	(parcel delivery)
PO Box 301463	1400 Coliseum Blvd.
Montgomery, AL 36130-1463	Montgomery, AL 36110-2059

An electronic version of this registration may be submitted to ADEM at TireMail@adem.state.al.us. Contact ADEM at 334-271-7988 for additional information about this registration form.

Regulations in ADEM Admin. Code 335 may be found on the ADEM web site at: www.adem.state.al.us/Regulations. Scrap tire regulations are in Division 4.

ADEM Form 541 01/10