State Form 47273 "Waste Tire Manifest" - Indiana

What Is State Form 47273?

This is a legal form that was released by the Indiana Department of Environmental Management - a government authority operating within Indiana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2006;
  • The latest edition provided by the Indiana Department of Environmental Management;
  • 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 printable version of State Form 47273 by clicking the link below or browse more documents and templates provided by the Indiana Department of Environmental Management.

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Download State Form 47273 "Waste Tire Manifest" - Indiana

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WASTE TIRE MANIFEST
S tate Form 47273 (R 2/10-06)
Indiana Department of Environmental Management
INSTRUCTIONS:
1. Use of this form is required by 329 IAC 15-4-13 and IC 13-20-14-5.
2. The Waste Tire Transporter must complete this form for each shipment of waste tires.
3. Fill in all information. Generator, transporter, and receiving facility information may be pre-printed.
4. Give a copy of this form to the generator (source) of the waste tires.
5. Give a second copy of this form to the receiver of the waste tires as listed in IC 13-20-14-4.
6. Keep a copy of this form for your records for at least one (1) year.
7. For help with this form contact IDEM’s Office of Land Quality, Solid Waste Permits Section, at (317) 232-0066.
GENERATOR (SOURCE OF W ASTE TIRES)
Name
Telephone (including area code)
Address
Generator’s
Print Name
Authorized
Agent
City
State
Zip Code
Signature
DESCRIPTION OF SHIPM ENT
Pickup Date
Time
Tire Types and Amounts
G
G
Passenger tires
Truck tires
Pickup Location
G
G
Load Type
G
G
Oversize tires
Other tires
W hole Tire Count
W eight in Pounds
(check one)
G
G
Volume Cubic Yards
W eight in Tons
TRANSPORTER
Name
Telephone (including area code)
Address
Permit/Registration No.
State
City
State
Zip Code
I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE WAS PICKED UP AT THE
SITE DESCRIBED ABOVE AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE.
Driver's Name
Signature
DESTINATION
Name
Telephone (including area code)
Address
Permit/Registration No.
State
City
State
Zip Code
I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE HAS BEEN ACCEPTED
AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE, AND THAT I AM AN AUTHORIZED AGENT OF THE
REGISTRANT.
Name of Authorized Agent
Signature
Receipt Date
WASTE TIRE MANIFEST
S tate Form 47273 (R 2/10-06)
Indiana Department of Environmental Management
INSTRUCTIONS:
1. Use of this form is required by 329 IAC 15-4-13 and IC 13-20-14-5.
2. The Waste Tire Transporter must complete this form for each shipment of waste tires.
3. Fill in all information. Generator, transporter, and receiving facility information may be pre-printed.
4. Give a copy of this form to the generator (source) of the waste tires.
5. Give a second copy of this form to the receiver of the waste tires as listed in IC 13-20-14-4.
6. Keep a copy of this form for your records for at least one (1) year.
7. For help with this form contact IDEM’s Office of Land Quality, Solid Waste Permits Section, at (317) 232-0066.
GENERATOR (SOURCE OF W ASTE TIRES)
Name
Telephone (including area code)
Address
Generator’s
Print Name
Authorized
Agent
City
State
Zip Code
Signature
DESCRIPTION OF SHIPM ENT
Pickup Date
Time
Tire Types and Amounts
G
G
Passenger tires
Truck tires
Pickup Location
G
G
Load Type
G
G
Oversize tires
Other tires
W hole Tire Count
W eight in Pounds
(check one)
G
G
Volume Cubic Yards
W eight in Tons
TRANSPORTER
Name
Telephone (including area code)
Address
Permit/Registration No.
State
City
State
Zip Code
I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE WAS PICKED UP AT THE
SITE DESCRIBED ABOVE AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE.
Driver's Name
Signature
DESTINATION
Name
Telephone (including area code)
Address
Permit/Registration No.
State
City
State
Zip Code
I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE HAS BEEN ACCEPTED
AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE, AND THAT I AM AN AUTHORIZED AGENT OF THE
REGISTRANT.
Name of Authorized Agent
Signature
Receipt Date