"State of New Mexico Scrap Tire Manifest" - New Mexico

State of New Mexico Scrap Tire Manifest 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" - New Mexico

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STATE OF NEW MEXICO SCRAP TIRE MANIFEST
Manifest No. __________________
New Mexico Environment Department, 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
Telephone Number
___________________________________________ ____________________________________________ _______________________________________________
Street Address
Mailing Address
City, State, Zip Code
___________________________________________ Passenger Tires: #___________ or Weight ____________ [ ] Pounds [ ] Tons (check one)
Name of Final Destination
Truck Tires:
#___________ or Weight ____________ [ ] Pounds [ ] Tons (check one)
Has the generator been charged for the service? [ ] Yes [ ] No (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: ___________________________________ Date: _____________________
2. HAULER INFORMATION AND CERTIFICATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company Name
Contact Name
Telephone Number
NMED Hauler Registration No.
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.
Name of Driver (Printed): ________________________________________ Signature: ______________________________________ Date: _______________________
3. SECOND HAULER (if applicable) INFORMATION AND CERTIFICATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company Name
Contact Name
Telephone Number
NMED Hauler Registration No.
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.
Name of Driver (Printed): ________________________________________ Signature: ______________________________________ Date: _______________________
4. TIRES REMOVED BY HAULER FOR RESALE / REUSE
___________________________________________________
______________________________________________________
_____________________
Company Name
Contact Name
Telephone Number
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
Passenger Tires Removed: # ________________ or
Weight _______________ [ ] Pounds [ ] Tons (check one)
Truck Tires Removed:
# ________________ 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.
Printed Name of Driver: __________________________________ Driver’s Signature: ______________________________________ Date: _______________________
5. FINAL DESTINATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company / Facility Name
Contact Name
Telephone Number
Permit or Registration No.
___________________________________________ _____________________________________
________________________________________________
Street Address
Mailing Address
City, State, Zip Code
Passenger Tires Received: # ____________ or Weight ________________ [ ] Pounds [ ] Tons (check one)
Truck Tires Received:
# ____________ 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
Date
Discrepancy Block / Special Instructions:
[Revised 6/12/2015]
STATE OF NEW MEXICO SCRAP TIRE MANIFEST
Manifest No. __________________
New Mexico Environment Department, 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
Telephone Number
___________________________________________ ____________________________________________ _______________________________________________
Street Address
Mailing Address
City, State, Zip Code
___________________________________________ Passenger Tires: #___________ or Weight ____________ [ ] Pounds [ ] Tons (check one)
Name of Final Destination
Truck Tires:
#___________ or Weight ____________ [ ] Pounds [ ] Tons (check one)
Has the generator been charged for the service? [ ] Yes [ ] No (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: ___________________________________ Date: _____________________
2. HAULER INFORMATION AND CERTIFICATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company Name
Contact Name
Telephone Number
NMED Hauler Registration No.
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.
Name of Driver (Printed): ________________________________________ Signature: ______________________________________ Date: _______________________
3. SECOND HAULER (if applicable) INFORMATION AND CERTIFICATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company Name
Contact Name
Telephone Number
NMED Hauler Registration No.
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.
Name of Driver (Printed): ________________________________________ Signature: ______________________________________ Date: _______________________
4. TIRES REMOVED BY HAULER FOR RESALE / REUSE
___________________________________________________
______________________________________________________
_____________________
Company Name
Contact Name
Telephone Number
____________________________________________ ____________________________________________ ________________________________________________
Street Address
Mailing Address
City, State, Zip Code
Passenger Tires Removed: # ________________ or
Weight _______________ [ ] Pounds [ ] Tons (check one)
Truck Tires Removed:
# ________________ 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.
Printed Name of Driver: __________________________________ Driver’s Signature: ______________________________________ Date: _______________________
5. FINAL DESTINATION
____________________________________________ ____________________________________________ _____________________ _________________________
Company / Facility Name
Contact Name
Telephone Number
Permit or Registration No.
___________________________________________ _____________________________________
________________________________________________
Street Address
Mailing Address
City, State, Zip Code
Passenger Tires Received: # ____________ or Weight ________________ [ ] Pounds [ ] Tons (check one)
Truck Tires Received:
# ____________ 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
Date
Discrepancy Block / Special Instructions:
[Revised 6/12/2015]