"Scrap Tire Transportation Manifest" - Georgia (United States)

Scrap Tire Transportation Manifest is a legal document that was released by the Georgia Department of Natural Resources - a government authority operating within Georgia (United States).

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Scrap Tire Transportation Manifest
Part I of this form shall be completed and signed by the scrap tire generator each time that scrap tires are transported to an end user, processor, sorter, or
disposal facility. Part II shall be completed and signed by the tire carrier. An authorized representative of the end user, processor, sorter, or disposal facility
(approved by the Georgia EPD) shall sign Part III. An authorized representative of the scrap tire generator shall sign Part IV. All parties shall complete all
information.
Part I: Certification by Scrap Tire Generator
Scrap Tire Generator: _____________________________________________________ ID#:_________________________
Business Address:________________________________________________________ City:_________________________
State:________ Zip:_____________ County:______________________________ Phone:____________________________
Enter amount of scrap tires to be transported in the applicable box:
Number of tires or
Tons of tires
(The estimated amount of tires must be within 10% of amount in Part III)
Tons of processed tires (cut, shredded, etc.) to be transported:_________________ (if applicable)
Destination of Tires:___________________________________________________________________________________
Location Address:____________________________________________________________ Phone:___________________
I hereby certify that the above indicated scrap tires were collected in the normal course of business in ______________County, State of
Georgia and are destined to be transported to the facility indicated above.
Signed:_____________________________________________Date:_____________________
Scrap Tire Generator Authorized Representative
Part II: Certification by Permitted Tire Carrier
Tire Carrier:__________________________________________________________ GA Permit #:______________________
Business Address:______________________________________________________ City: ____________________________
State:________ Zip:__________ Phone:_______________________
I hereby certify that the scrap tires received from the scrap tire generator (see Part I of this form) will be delivered to the destination designated
by said generator and that the completed and signed manifest will be returned to the generator within 30 days from this date.
Signed:____________________________________________ Date:_____________________
Tire Carrier Authorized Representative
Part III: Certification by End User/Processor/Sorter/Disposal Facility
End User/Processor/Sorter/Disposal Facility:______________________________ GA Permit # (if applicable):_____________
Address:______________________________________________City:_________________________ State:______________
Zip:______________ Phone:_______________________
I hereby certify that this facility is permitted or approved by the Georgia Environmental Protection Division to receive scrap
tires and that I have received:
number of tires or
tons of tires, on the date below.
Signed:__________________________________________________Date:_____________________
End User, Processor, Sorter, or Disposal Facility Authorized Representative
Part IV: Certification by Scrap Tire Generator
I hereby certify that I received a completed and signed manifest from the tire carrier listed in Part II of this form on the date below.
Signed:____________________________________________ Date:_____________________
Scrap Tire Generator Authorized Representative
Georgia Environmental Protection Division | 4244 International Parkway | Suite 104 | Atlanta, GA 30354 | 404-363-7027
Scrap Tire Transportation Manifest
Part I of this form shall be completed and signed by the scrap tire generator each time that scrap tires are transported to an end user, processor, sorter, or
disposal facility. Part II shall be completed and signed by the tire carrier. An authorized representative of the end user, processor, sorter, or disposal facility
(approved by the Georgia EPD) shall sign Part III. An authorized representative of the scrap tire generator shall sign Part IV. All parties shall complete all
information.
Part I: Certification by Scrap Tire Generator
Scrap Tire Generator: _____________________________________________________ ID#:_________________________
Business Address:________________________________________________________ City:_________________________
State:________ Zip:_____________ County:______________________________ Phone:____________________________
Enter amount of scrap tires to be transported in the applicable box:
Number of tires or
Tons of tires
(The estimated amount of tires must be within 10% of amount in Part III)
Tons of processed tires (cut, shredded, etc.) to be transported:_________________ (if applicable)
Destination of Tires:___________________________________________________________________________________
Location Address:____________________________________________________________ Phone:___________________
I hereby certify that the above indicated scrap tires were collected in the normal course of business in ______________County, State of
Georgia and are destined to be transported to the facility indicated above.
Signed:_____________________________________________Date:_____________________
Scrap Tire Generator Authorized Representative
Part II: Certification by Permitted Tire Carrier
Tire Carrier:__________________________________________________________ GA Permit #:______________________
Business Address:______________________________________________________ City: ____________________________
State:________ Zip:__________ Phone:_______________________
I hereby certify that the scrap tires received from the scrap tire generator (see Part I of this form) will be delivered to the destination designated
by said generator and that the completed and signed manifest will be returned to the generator within 30 days from this date.
Signed:____________________________________________ Date:_____________________
Tire Carrier Authorized Representative
Part III: Certification by End User/Processor/Sorter/Disposal Facility
End User/Processor/Sorter/Disposal Facility:______________________________ GA Permit # (if applicable):_____________
Address:______________________________________________City:_________________________ State:______________
Zip:______________ Phone:_______________________
I hereby certify that this facility is permitted or approved by the Georgia Environmental Protection Division to receive scrap
tires and that I have received:
number of tires or
tons of tires, on the date below.
Signed:__________________________________________________Date:_____________________
End User, Processor, Sorter, or Disposal Facility Authorized Representative
Part IV: Certification by Scrap Tire Generator
I hereby certify that I received a completed and signed manifest from the tire carrier listed in Part II of this form on the date below.
Signed:____________________________________________ Date:_____________________
Scrap Tire Generator Authorized Representative
Georgia Environmental Protection Division | 4244 International Parkway | Suite 104 | Atlanta, GA 30354 | 404-363-7027