Form CalRecycle774O "Tire Incentive Program (Tip3) Certification" - California

What Is Form CalRecycle774O?

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 May 1, 2016;
  • 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 CalRecycle774O 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 CalRecycle774O "Tire Incentive Program (Tip3) Certification" - California

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State of California
Grantee Name
Department of Resources Recycling and Recovery (CalRecycle)
CalRecycle 774o (Rev.5/16)
Grantee Number
Tire Incentive Program (TIP3) Certification
Instructions are located on the reverse side. This form is used in
conjunction with your supporting documentation.
Product Weight
Incentive Rate
Incentive Total
Incentive Category
TIP Product Description
x
=
(pounds)
(per pound)
(product weight x incentive rate)
= $
General Cost
x
5 cents
New or
= $
x
10 cents
Existing TDP
Feedstock
x
30 cents
= $
Conversion
= $
Fine (<50) Mesh
x
40 cents
Previousl y Awarded products at a 70 percent reimbursement
Previousl y Awarded
x
7 cents
= $
Existing TDP
Previously Awarded
x
21 cents
= $
Feedstock Conversion
Previousl y Awarded
x
28 cents
= $
Fine (<50) Mesh
TOTAL $
For Payment Request. Under the laws of California: I certify under penalty of perj ury that I am legally authorized to contractually bind and
make the following representations on behalf of the above-named grantee, and pursuant to that authorization I further certify under penalty of
perjury: 1) that all information provided herein is true and correct; 2) that the tire material in the product(s) described above is from only
California-generated waste tires with a certification for the California waste tire processor attesting to that fact; 3) that the waste tires were
processed and manufactured into a final product in California; 4) that the above named grantee and CalRecycle can rely on this certification
for purposes of identifying crumb rubber purchased and incentive payment amounts, respectively; 5) that the above-named grantee
acknowledges that if the tire material in the product(s) cannot be verified to be from only California-generated waste tires and/or that the
waste tires were not processed and manufactured into a final product in California, the manufacturer may be considered for placement on the
CalRecycle Unreliable List (14 CRR § 17050 et seq.), in addition to any other action(s) CalRecycle may have against the grantee.
 
 
 
Clear
Print
State of California
Grantee Name
Department of Resources Recycling and Recovery (CalRecycle)
CalRecycle 774o (Rev.5/16)
Grantee Number
Tire Incentive Program (TIP3) Certification
Instructions are located on the reverse side. This form is used in
conjunction with your supporting documentation.
Product Weight
Incentive Rate
Incentive Total
Incentive Category
TIP Product Description
x
=
(pounds)
(per pound)
(product weight x incentive rate)
= $
General Cost
x
5 cents
New or
= $
x
10 cents
Existing TDP
Feedstock
x
30 cents
= $
Conversion
= $
Fine (<50) Mesh
x
40 cents
Previousl y Awarded products at a 70 percent reimbursement
Previousl y Awarded
x
7 cents
= $
Existing TDP
Previously Awarded
x
21 cents
= $
Feedstock Conversion
Previousl y Awarded
x
28 cents
= $
Fine (<50) Mesh
TOTAL $
For Payment Request. Under the laws of California: I certify under penalty of perj ury that I am legally authorized to contractually bind and
make the following representations on behalf of the above-named grantee, and pursuant to that authorization I further certify under penalty of
perjury: 1) that all information provided herein is true and correct; 2) that the tire material in the product(s) described above is from only
California-generated waste tires with a certification for the California waste tire processor attesting to that fact; 3) that the waste tires were
processed and manufactured into a final product in California; 4) that the above named grantee and CalRecycle can rely on this certification
for purposes of identifying crumb rubber purchased and incentive payment amounts, respectively; 5) that the above-named grantee
acknowledges that if the tire material in the product(s) cannot be verified to be from only California-generated waste tires and/or that the
waste tires were not processed and manufactured into a final product in California, the manufacturer may be considered for placement on the
CalRecycle Unreliable List (14 CRR § 17050 et seq.), in addition to any other action(s) CalRecycle may have against the grantee.
 
 
Audit/Records Access. The grantee agrees to be bound by the Audit/Records Access provision in the Terms and Conditions of the TIP.
Please refer to your TIP grant file or contact CalRecycle for a copy of the Terms and Conditions.
Signature of Signature Authority
Print Name
Title
Date
(as authorized in the Letter of Commitment )
INSTRUCTIONS
Grantee Name. Enter the legal name as it appears on the Grant Agreement Cover Sheet or Application in GMS.
Grant Number. Enter Grant number as shown on the Grant Agreement Cover Sheet.
Supporting Documentation. Check the box(es) if supporting documentation is uploaded to GMS.
Complete the Table. See the example below.
1. Choose the Incentive Category in the first column and enter the product description in the second column.
2. Enter the Product Weight in pounds in the third column.
3. Multiply the Product Weight and the Incentive Rate. Enter the Incentive Total in the seventh column.
4. Enter the sum of all entries in the seventh column in the “Total” box.
Incentive Categories Costs (crumb rubber usage)
1. General Cost. An incentive is based on the crumb rubber portion of all TIP-eligible TDPs sold and shipped during the grant term
(regardless whether the products are included in a TIP award).
2. New or Existing TDP. The incremental increase in usage of crumb rubber (compared with the previous year’s records, i.e. “baseline”)
for the production of an eligible product. TDPs with no previous sales have no baseline and will receive the incentive for the sale of an
eligible product during the Grant Term.
3. Feedstock Conversion. The crumb rubber usage for products currently manufactured with virgin rubber, plastic or other material
which will be substituted with a minimum of five percent crumb rubber and may be co-extruded, injected, calendered or otherwise
combined.
4. Fine (≤ 50) Mesh. The crumb rubber usage for new or existing TDPs must be produced using fine (≤50) mesh provided by a California
waste tire processor Particle size and particle size distribution are determined in accordance with American Society for Testing and
Materials (ASTM) D5644 and D5603.
Signature of Signature Authority. Must be signed by the person authorized in the Letter of Commitment.
Print Name, Title, and Date. Print the name of the signature authority, the title and date the form is signed.
Upload to GMS. Please reference the Payment Request and Documentation section of the Procedures and Requirements for
instructions.
 
 
Example
Product Weight
Incentive Rate
Incentive Total
Incentive Category
Product Description
x
=
(pounds)
(per pound)
(product weight x incentive rate)
Ten TIP-eligible TDPs
1. General Cost
80,000
x
5 cents
=
$
4,000
(see attached list)
2. New or
Rubber Widget
20,000
x
10 cents
=
$
2,000
Existing TDP
3. Feedstock
New Improved Rubber Widget
35,000
x
30 cents
=
$ 10,500
Conversion
4. Fine (<50)
New Rubber Widget with Fine Mesh
15,000
x
40 cents
=
$
Mesh
6,000
TOTAL
$ 22,500
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