Form CalRecycle241 "Application for Agricultural/Common Carrier Exemption Letter" - California

What Is Form CalRecycle241?

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 April 1, 2010;
  • 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 CalRecycle241 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 CalRecycle241 "Application for Agricultural/Common Carrier Exemption Letter" - California

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State of California
Department of Resources Recycling and Recovery (CalRecycle)
CalRecycle 241 (Rev. 04/10)
Application For
Agricultural/Common Carrier Exemption Letter
Pursuant to Sections 42954 (a)(5) and 42954(a)(6) of the Public Resources Code, and Section 18453 of Title 14, California Code of
Regulations, the applicant shall submit the following information on this form in order to obtain a Waste Tire Hauler Registration Exemption for
Agricultural or Common Carrier approval to transport used or waste tires.
APPLICANT: COMPLETE (TYPE OR PRINT IN INK) ITEMS 1 THROUGH 7. IF A SPECIFIC ITEM DOES NOT APPLY TO YOUR
COMPANY, ENTER "N/A", FOR NOT APPLICABLE. INCOMPLETE OR PHOTOCOPIED FORMS MAY BE REJECTED & RETURNED.
1. Business Name(s)*:
__________________________________________________________________________
2. Name of Business Owner
____________________________________________________________________
Phone Number (
_
____
)
_____ _________________
-
Social Security Number
______ ______ ______
-
-
**
3. Name of Business Operator or Manager (If different than No. 2):
_______________________________________
Phone Number (
_
____ _____ _________________
)
-
4. Other business names that you are using for tire-related businesses (DBA's):
_____________________________
5. Business Facility Address:
_____________________________________________________________________
City:
_________________________________
State:
___________________________
Zip:
__________________
6. Mailing address of business (if different than No. 5):
_________________________________________________
City:
_________________________________
State:
___________________________
Zip:
__________________
7. I am applying for (select only one)
Agricultural Exemption
Common Carrier Exemption
I certify under penalty of perjury under the laws of the State of California that the information provided herein is true and correct:
Signature of Authorized Agent of Business:
___________________________________________________________
Printed Name of Authorized Agent of Business:
_______________________________________________________
Title of Authorized Agent:
________________________________________________________________________
Date:
___________________________
RETURN COMPLETED FORM TO:
Department of Resources Recycling and Recovery (CalRecycle)
Tire Hauler Compliance Section
P.O. Box 4025
Sacramento, CA 95812
* Name of individual, sole proprietorship, co-partnership, Limited Liability Company, corporation, or political subdivision applying for registration.
** Pursuant to Family Code Section 17520(d), persons applying for issuance or renewal of any license or other authorization to engage in a business,
occupation, or profession under any of the laws administered by the Department, must provide their social security numbers to the Department.
The Department uses this information to match their names to the names on the list provided by the Department of Child Support Services, and to
respond to requests for information made by child support agencies. Please be advised that this social security number may be used for Department
enforcement and/or collection of penalties when needed. Please note that this section does not apply to Limited Liability Companies, corporations,
or political subdivisions.
Clear
Print
State of California
Department of Resources Recycling and Recovery (CalRecycle)
CalRecycle 241 (Rev. 04/10)
Application For
Agricultural/Common Carrier Exemption Letter
Pursuant to Sections 42954 (a)(5) and 42954(a)(6) of the Public Resources Code, and Section 18453 of Title 14, California Code of
Regulations, the applicant shall submit the following information on this form in order to obtain a Waste Tire Hauler Registration Exemption for
Agricultural or Common Carrier approval to transport used or waste tires.
APPLICANT: COMPLETE (TYPE OR PRINT IN INK) ITEMS 1 THROUGH 7. IF A SPECIFIC ITEM DOES NOT APPLY TO YOUR
COMPANY, ENTER "N/A", FOR NOT APPLICABLE. INCOMPLETE OR PHOTOCOPIED FORMS MAY BE REJECTED & RETURNED.
1. Business Name(s)*:
__________________________________________________________________________
2. Name of Business Owner
____________________________________________________________________
Phone Number (
_
____
)
_____ _________________
-
Social Security Number
______ ______ ______
-
-
**
3. Name of Business Operator or Manager (If different than No. 2):
_______________________________________
Phone Number (
_
____ _____ _________________
)
-
4. Other business names that you are using for tire-related businesses (DBA's):
_____________________________
5. Business Facility Address:
_____________________________________________________________________
City:
_________________________________
State:
___________________________
Zip:
__________________
6. Mailing address of business (if different than No. 5):
_________________________________________________
City:
_________________________________
State:
___________________________
Zip:
__________________
7. I am applying for (select only one)
Agricultural Exemption
Common Carrier Exemption
I certify under penalty of perjury under the laws of the State of California that the information provided herein is true and correct:
Signature of Authorized Agent of Business:
___________________________________________________________
Printed Name of Authorized Agent of Business:
_______________________________________________________
Title of Authorized Agent:
________________________________________________________________________
Date:
___________________________
RETURN COMPLETED FORM TO:
Department of Resources Recycling and Recovery (CalRecycle)
Tire Hauler Compliance Section
P.O. Box 4025
Sacramento, CA 95812
* Name of individual, sole proprietorship, co-partnership, Limited Liability Company, corporation, or political subdivision applying for registration.
** Pursuant to Family Code Section 17520(d), persons applying for issuance or renewal of any license or other authorization to engage in a business,
occupation, or profession under any of the laws administered by the Department, must provide their social security numbers to the Department.
The Department uses this information to match their names to the names on the list provided by the Department of Child Support Services, and to
respond to requests for information made by child support agencies. Please be advised that this social security number may be used for Department
enforcement and/or collection of penalties when needed. Please note that this section does not apply to Limited Liability Companies, corporations,
or political subdivisions.