Form CalRecycle740-TDA "Tire Derived Aggregate (Tda) Certification" - California

What Is Form CalRecycle740-TDA?

This is a legal form that was released by the California Department of Resources Recycling and Recovery - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the California Department of Resources Recycling and Recovery;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CalRecycle740-TDA by clicking the link below or browse more documents and templates provided by the California Department of Resources Recycling and Recovery.

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Download Form CalRecycle740-TDA "Tire Derived Aggregate (Tda) Certification" - California

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STATE OF CALIFORNIA
Grantee Name:
(
)
DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY
CALRECYCLE
740- TDA (8/13)
CALRECYCLE
Grant Number:
Tire Derived Aggregate (TDA) Certification
This TDA Certification form must be completed by each TDA manufacturer or contractor who provides TDA product for the above referenced grant. By signing
this form, the signatory certifies, under penalty of perjury, that (s)he is authorized to sign this document on behalf of the TDA manufacturer or contractor named
below and that the information is true and accurate.
Grantee: Request completion of this form by each TDA manufacturer or contractor who provides TDA product for your grant project. Review the form for
accuracy and completeness and include it with the Payment Request form submitted for reimbursement for the TDA product described below. Retain a copy of
this document and all supporting documentation showing that the tire material used for your grant project is from only California-generated waste tires.
TDA manufacturer or contractor: See instructions on the next page, complete and submit this form and supporting documentation to Grantee.
:
:
TDA MANUFACTURER OR CONTRACTOR NAME
EMAIL
:
:
:
CONTACT NAME
PHONE
FAX
:
:
ADDRESS
WEBSITE
SUPPORTING DOCUMENTATION REQUIREMENT
(
)
CERTIFICATE OF ORIGIN OR ACCEPTABLE SUPPORTING DOCUMENTATION ATTACHED SEE FOOTNOTES ON NEXT PAGE
Product Description
Manufacturer Name
Quantity
/
Passenger Tire
Number of PTE’s
=
Equivalent (PTE)
(lbs.)
(divided)
Diverted
TDA Material (Type A, Type B, other)
E X A M P L E
25,000
/
20 lbs/tire
1,250
=
/
=
/
=
TOTAL:
The Product Provider agrees to be bound by the Audit/Records Access requirements of the above-referenced Grant. See next page for additional detail.
I certify under penalty of perjury that I am an authorized signatory for the above named TDA manufacturer or contractor and that the material provided to the
above-named grantee is manufactured from only California-generated waste tires. I understand that if it cannot be verified that the source of the material is
from only California-generated waste tires, or if an audit discloses the use of non-California waste tires, that the CalRecycle may deny reimbursement of this
cost and/or require the grantee to return some or all grant funds previously paid under this grant, and that the grantee may seek reimbursement from the
above-named TDA manufacturer or contractor for the TDA material costs and related damages.
Signature of Authorized Signatory for TDA manufacturer or contractor
Print Name
Title
Date
1
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STATE OF CALIFORNIA
Grantee Name:
(
)
DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY
CALRECYCLE
740- TDA (8/13)
CALRECYCLE
Grant Number:
Tire Derived Aggregate (TDA) Certification
This TDA Certification form must be completed by each TDA manufacturer or contractor who provides TDA product for the above referenced grant. By signing
this form, the signatory certifies, under penalty of perjury, that (s)he is authorized to sign this document on behalf of the TDA manufacturer or contractor named
below and that the information is true and accurate.
Grantee: Request completion of this form by each TDA manufacturer or contractor who provides TDA product for your grant project. Review the form for
accuracy and completeness and include it with the Payment Request form submitted for reimbursement for the TDA product described below. Retain a copy of
this document and all supporting documentation showing that the tire material used for your grant project is from only California-generated waste tires.
TDA manufacturer or contractor: See instructions on the next page, complete and submit this form and supporting documentation to Grantee.
:
:
TDA MANUFACTURER OR CONTRACTOR NAME
EMAIL
:
:
:
CONTACT NAME
PHONE
FAX
:
:
ADDRESS
WEBSITE
SUPPORTING DOCUMENTATION REQUIREMENT
(
)
CERTIFICATE OF ORIGIN OR ACCEPTABLE SUPPORTING DOCUMENTATION ATTACHED SEE FOOTNOTES ON NEXT PAGE
Product Description
Manufacturer Name
Quantity
/
Passenger Tire
Number of PTE’s
=
Equivalent (PTE)
(lbs.)
(divided)
Diverted
TDA Material (Type A, Type B, other)
E X A M P L E
25,000
/
20 lbs/tire
1,250
=
/
=
/
=
TOTAL:
The Product Provider agrees to be bound by the Audit/Records Access requirements of the above-referenced Grant. See next page for additional detail.
I certify under penalty of perjury that I am an authorized signatory for the above named TDA manufacturer or contractor and that the material provided to the
above-named grantee is manufactured from only California-generated waste tires. I understand that if it cannot be verified that the source of the material is
from only California-generated waste tires, or if an audit discloses the use of non-California waste tires, that the CalRecycle may deny reimbursement of this
cost and/or require the grantee to return some or all grant funds previously paid under this grant, and that the grantee may seek reimbursement from the
above-named TDA manufacturer or contractor for the TDA material costs and related damages.
Signature of Authorized Signatory for TDA manufacturer or contractor
Print Name
Title
Date
1
INSTRUCTIONS:
Grantee to provide:
1. Grantee Name: Complete full legal name as it appears on the TDA Grant Agreement Cover Sheet.
2. Grant Number: Enter assigned grant number.
TDA manufacturer, or contractor to provide:
1. Contact information: Provide your business’ contact information in this section.
2. Supporting documentation requirement: Provide the grantee with copies of supporting documentation that validates only California-generated waste
tires were used for this grant project and that the waste tires were processed in California. Acceptable forms of supporting documentation include:
Certificate of Origin (if completed by a California Processor) or a Bill of Lading and Manifest documentation for non-California processors.
3. Number of tires diverted: Provide the total number of tires diverted in Passenger Tire Equivalents for this project. Include both the number of pounds
of TDA material and the calculated number of Passenger Tire Equivalent (PTEs): Use 20 pounds of rubber per PTE.
4. Signature: This form must be signed by an authorized signatory of the TDA manufacturer or contractor. Provide the completed form, with supporting
documentation, to the grantee.
AUDIT/RECORDS ACCESS:
The Product Provider agrees that CalRecycle, the Department of Finance, the Bureau of State Audits, or their designated representative(s) shall have the right to
review and to copy any records and supporting documentation pertaining to this Certification or the products certified herein. The Product Provider agrees to
maintain such records for possible audit for a minimum of three (3) years after final payment date or grant term end date, whichever is later, unless a longer period
of records retention is stipulated, or until completion of any action and resolution of all issues which may arise as a result of any litigation, dispute, or audit,
whichever is later. The Product Provider agrees to allow the designated representative(s) access to such records during normal business hours and to allow
interviews of any employees who might reasonably have information related to such records. Further, the Product Provider agrees to include a similar right of the
State to audit records and interview staff in any contract or subcontract related to this Certification or the products certified herein.
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