Waste Tire Exemption Request
Contact Person Company or Community
Mailing Address Phone
Physical Address and Tire Storage Location
Reason for Event / Request & Event Date(s)
Expected Number of Tires at Event
(if annual collection request, estimate annual number)
17 1/2 in. or less ≥17 1/2 in. ≤ 19.5 in. > 19 1/2 in.
Please initial that you agree to terms of exemption requirements
No tires with rims will be collected during event.
Tires collected will only be collected for the above reasons and during the above event.
No tires will be collected from any other source or event. (such as: tire
dealerships, salvage yards, service stations,etc.)
No exempt tires will be collected. (such as: forklift, offroad, heavy machinery,
agricultural or tractor, and backhoe tires, etc.)
A report will be submitted to the DEQ, listing the number of tires collected, once the event
is complete or annually, whichever is determined by the DEQ.
By siging this request, I agree to maintain the requirements of the waste tire exemption authorization,
issued by the DEQ. Responsible party sign in
the following box.
FOR DEQ USE ONLY. DO NOT WRITE BELOW THIS LINE
S or R #
DEQ Form August 2008