"State of New Mexico Scrap Tire Manifest Self-hauling Generator Form" - New Mexico

State of New Mexico Scrap Tire Manifest Self-hauling Generator Form is a legal document that was released by the New Mexico Environment Department - a government authority operating within New Mexico.

Form Details:

  • Released on June 12, 2015;
  • The latest edition currently provided by the New Mexico Environment Department;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New Mexico Environment Department.

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Download "State of New Mexico Scrap Tire Manifest Self-hauling Generator Form" - New Mexico

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STATE OF NEW MEXICO SCRAP TIRE MANIFEST
Manifest No. ____________________
Self-Hauling Generator Form
This form is only for use by scrap tire generators that self-haul scrap tires to the final destination.
NMED Solid Waste Bureau, P.O. Box 5469, Santa Fe, New Mexico 87502-5469, (505) 827-0559
1. GENERATOR INFORMATION AND CERTIFICATION
________________________________
________________________________
___________________
Generator (Business Name)
Contact Name
Date of Transport
________________________________
______________________ _______________________________
Street Address
Mailing Address
City, State, Zip Code
_____________________________
_________________________________________________
Telephone Number
E-Mail Address (Optional)
Passenger Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Truck Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this
manifest may result in enforcement action.
Generator or Authorized Agent (Printed): ________________________ Signature: ________________________
2. FINAL DESTINATION
________________________________
________________________________
___________________
Company / Facility Name
Contact Name
Date of Drop-off
________________________________
______________________ _______________________________
Street Address
Mailing Address
City, State, Zip Code
____________________________ _____________________________ _______________________________
Permit or Registration No.
Telephone Number
E-Mail Address (Optional)
Passenger Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Truck Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Weight of Mixed Load of Passenger and Truck Tires Received _________ [ ] Pounds [ ] Tons
(check one)
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this
manifest may result in enforcement action.
Final Destination Representative (Printed): _____________________
Signature: _______________________
[Revised 6/12/2015]
STATE OF NEW MEXICO SCRAP TIRE MANIFEST
Manifest No. ____________________
Self-Hauling Generator Form
This form is only for use by scrap tire generators that self-haul scrap tires to the final destination.
NMED Solid Waste Bureau, P.O. Box 5469, Santa Fe, New Mexico 87502-5469, (505) 827-0559
1. GENERATOR INFORMATION AND CERTIFICATION
________________________________
________________________________
___________________
Generator (Business Name)
Contact Name
Date of Transport
________________________________
______________________ _______________________________
Street Address
Mailing Address
City, State, Zip Code
_____________________________
_________________________________________________
Telephone Number
E-Mail Address (Optional)
Passenger Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Truck Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this
manifest may result in enforcement action.
Generator or Authorized Agent (Printed): ________________________ Signature: ________________________
2. FINAL DESTINATION
________________________________
________________________________
___________________
Company / Facility Name
Contact Name
Date of Drop-off
________________________________
______________________ _______________________________
Street Address
Mailing Address
City, State, Zip Code
____________________________ _____________________________ _______________________________
Permit or Registration No.
Telephone Number
E-Mail Address (Optional)
Passenger Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Truck Tires:
Total #_________ or Weight__________ [ ] Pounds [ ] Tons
(check one)
Weight of Mixed Load of Passenger and Truck Tires Received _________ [ ] Pounds [ ] Tons
(check one)
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this
manifest may result in enforcement action.
Final Destination Representative (Printed): _____________________
Signature: _______________________
[Revised 6/12/2015]