Waste Tire Facility Annual Report Form (WT-5)

Calendar Year 2023

Annual Waste Tire Facility Activity Report for the period of

January 1, 2023 - December 31, 2023

Facility information

Facility name *

Certificate of Registration number *

Street address *

County *

City or town *

State *

Zip *

Is your mailing address the same as your physical address? *

Yes

Mailing address *

City or town *

State *

Zip *

Facility contact name *

Telephone *

Fax number

Email address *

This reporting form must be submitted by March 1 of each year for the previous calendar year's waste tire activities.

If you have any questions regarding this form, please contact Shana Baker at 303-692-3305 (1-888-569-1831 ext. 3305 toll-free) or send an email to cdphe.hmwastetires@state.co.us.

Reporting

Under 6 CCR 1007-2 Section 10 of the Colorado Regulations Pertaining to Solid Waste Sites and Facilities, waste tire monofills, processors, end users, and collection facilities must report annually to the department on or before March 1st of each year, reporting on their waste tire and/or tire-derived product activities of the previous calendar year. A waste tire monofill must provide information concerning compliance with their Waste Tire Inventory Reduction Plan. A waste tire processor must be able to demonstrate that the quantity of waste tires that were processed into tire-derived product during the calendar year was at least 75% of the waste tire inventory based on a three (3) year rolling average.