Application For South Carolina Waste Tire Hauler Registration
Used for Transporting Waste Tires to a:
o Collection Facility / Landfill
or
o Processing Facility
Part I: Certification by Registered Waste Tire Hauler:
Type of registration being applied for:
o
o
o
New
Temporary - 29-day - for Site Cleanup
Yearly Renewal
o
o
Self-hauler
Hauler for hire
If renewal application, please provide your Waste Tire Hauler, Self-hauler or Hauler for Hire Registration Number: ___________
Waste Tire Hauler’s Business Name: ____________________________________________________________________________
Owner/ Operator Name: ______________________________________________________________________________________
o
o
o
o
Please check one:
Incorporated
Limited Liability Company
Sole Proprietorship
Other (specify): _____________
Business Address: ________________________________________________ E-mail Address ____________________________
City: ____________________________________ State: __________ Zip Code: __________ County: _______________________
Business Phone: __________________________ Cell Phone: ________________________ Fax number ____________________
Business Mailing Address (if different from above): _________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________
Home Address: _____________________________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________ Home Phone: __________________
Identification - Drivers License
State: _______________ Drivers License Number: ______________________________
o
South Carolina Counties Serviced:
All
or
List Each County:________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Certification Statement and Notary:
I, as the waste tire hauler, hereby declare that the information submitted in this application for registration is accurate and complete.
I
am aware the there are penalties for submitting false information, including the possibility of fines and imprisonment. I understand that
this registration will authorize the waste tire hauler to transport waste tires from the retailer/generator to the listed permitted waste tire
processing facility, landfill or collection facility only. I am also aware that under this registration I am required to use the Department
approved waste tire manifest and I will provide the completed and signed manifest to the retailer/generator of the waste tires within
30-days and retain a copy of the completed and signed manifest for my records per Regulation 61-107.3. In addition, I will update this
application during the year if I add and/or delete a facility from the original submission. I acknowledge that disposal of waste tires outside
of a permitted facility or Department approved facility is violation of Regulation 61-107.3. Finally, I certify that I have read this statement
and understand it in its entirety and that, if not the owner/ operator, I am authorized to sign official documents for the applicant.
Signature: ________________________________________
Date of Signature: ___________________
Print Name and Title: _____________________________________________________________________
I hereby authenticate the signature of the application.
Sworn to before me this ________day of _____________________, 20_______
_________________________________________
Notary Public for South Carolina
My Commission Expires: ____________________
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 2735 (11/2015)
Page 1 of 3
Application For South Carolina Waste Tire Hauler Registration
Used for Transporting Waste Tires to a:
o Collection Facility / Landfill
or
o Processing Facility
Part I: Certification by Registered Waste Tire Hauler:
Type of registration being applied for:
o
o
o
New
Temporary - 29-day - for Site Cleanup
Yearly Renewal
o
o
Self-hauler
Hauler for hire
If renewal application, please provide your Waste Tire Hauler, Self-hauler or Hauler for Hire Registration Number: ___________
Waste Tire Hauler’s Business Name: ____________________________________________________________________________
Owner/ Operator Name: ______________________________________________________________________________________
o
o
o
o
Please check one:
Incorporated
Limited Liability Company
Sole Proprietorship
Other (specify): _____________
Business Address: ________________________________________________ E-mail Address ____________________________
City: ____________________________________ State: __________ Zip Code: __________ County: _______________________
Business Phone: __________________________ Cell Phone: ________________________ Fax number ____________________
Business Mailing Address (if different from above): _________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________
Home Address: _____________________________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________ Home Phone: __________________
Identification - Drivers License
State: _______________ Drivers License Number: ______________________________
o
South Carolina Counties Serviced:
All
or
List Each County:________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Certification Statement and Notary:
I, as the waste tire hauler, hereby declare that the information submitted in this application for registration is accurate and complete.
I
am aware the there are penalties for submitting false information, including the possibility of fines and imprisonment. I understand that
this registration will authorize the waste tire hauler to transport waste tires from the retailer/generator to the listed permitted waste tire
processing facility, landfill or collection facility only. I am also aware that under this registration I am required to use the Department
approved waste tire manifest and I will provide the completed and signed manifest to the retailer/generator of the waste tires within
30-days and retain a copy of the completed and signed manifest for my records per Regulation 61-107.3. In addition, I will update this
application during the year if I add and/or delete a facility from the original submission. I acknowledge that disposal of waste tires outside
of a permitted facility or Department approved facility is violation of Regulation 61-107.3. Finally, I certify that I have read this statement
and understand it in its entirety and that, if not the owner/ operator, I am authorized to sign official documents for the applicant.
Signature: ________________________________________
Date of Signature: ___________________
Print Name and Title: _____________________________________________________________________
I hereby authenticate the signature of the application.
Sworn to before me this ________day of _____________________, 20_______
_________________________________________
Notary Public for South Carolina
My Commission Expires: ____________________
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
DHEC 2735 (11/2015)
Page 1 of 3
Part II: Certification by Waste Tire Collection Facility, Landfill or Processing Facility
(Must be approved by SCDHEC or on the Waste Tire Rebate List)
Name of Facility: _____________________________________________________________________________________________
Facility Owner/ Operator: ______________________________________________________________________________________
Business Address: ___________________________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________ County: _______________________
Telephone: ______________________________ SC Permit Number (if applicable): ______________________________
I hereby certify that this facility is approved by SCDHEC to receive waste tires from South Carolina and that the facility has an agreement
with this waste tire hauler to receive waste tires for collection or processing.
Signed: ________________________________________________________ Date: ___________________________
Waste Tire Collection/ Processing Facility’s Representative
Name of Facility: _____________________________________________________________________________________________
Facility Owner/ Operator: ______________________________________________________________________________________
Business Address: ___________________________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________ County: _______________________
Telephone: ______________________________ SC Permit Number (if applicable): ______________________________
I hereby certify that this facility is approved by SCDHEC to receive waste tires from South Carolina and that the facility has an agreement
with this waste tire hauler to receive waste tires for collection or processing.
Signed: _______________________________________________________ Date: ___________________________
Waste Tire Collection/ Processing Facility’s Representative
Name of Facility: _____________________________________________________________________________________________
Facility Owner/ Operator: ______________________________________________________________________________________
Business Address: ___________________________________________________________________________________________
City: ____________________________________ State: __________ Zip Code: __________ County: _______________________
Telephone: ______________________________ SC Permit Number (if applicable): ______________________________
I hereby certify that this facility is approved by SCDHEC to receive waste tires from South Carolina and that the facility has an agreement
with this waste tire hauler to receive waste tires for collection or processing.
Signed: ________________________________________________________ Date: ___________________________
Waste Tire Collection/ Processing Facility’s Representative
This application will not be processed if it is incomplete or inaccurate. All renewal applications must be accompanied by an annual
report and must be received prior to March 1st of each year. Allow at least 30-days for the processing of the application. For questions
or to notify SCDHEC of any changes, call (803) 898-0495.
Please submit the application to the address below:
SCDHEC – BLWM
ATTN: Waste Tire Hauler Registration
Division of Compliance and Enforcement
2600 Bull Street
Columbia, South Carolina 29201-1708
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Page 2 of 3
DHEC 2735 (11/2015)
Instructions for Completing DHEC 2735
South Carolina Waste Tire Hauler Registration
Registration for Waste Tire Haulers Transporting to Waste Tire Collection Facility, Landfill or Processing Facilities
Purpose:
This form is used to obtain a waste tire hauler Permit to transport waste tires to a Department permitted or approved landfill, waste
tire collection or processing facility.
Explanation:
Any person engaged in transporting waste tires in South Carolina for the purpose of storage, disposal or processing must register
with the Department. A registered waste tire hauler shall only dispose of waste tires at a Department permitted or approved waste
tire collection or processing facility using this registration. To obtain a waste tire hauler registration, the applicant must complete
this registration form and submit it to the Department for review and approval prior to transporting waste tires in South Carolina.
This registration form, when approved by the Department and issued to the applicant, authorizes the waste tire hauler to operate
from the effective date of the registration until the expiration date (usually March 1st of the following year). It is the responsibility of
the waste tire hauler to renew annually. Renewal applications must be accompanied with the SC Waste Tire Hauler Annual Report.
A company or local government may submit one application to register its drivers. In this case the company‘s project manager
overseeing this area is the only drivers license information needed with the application. In the event of a change in personnel
before the renewal date, it is critical that we be notified immediately.
Instructions:
Part I: Certification by Waste Tire Hauler:
Complete all items on this part of the form. Check “New” if this is the first time the applicant has applied for this type of waste tire
hauler registration. Check “Temporary” if this is going to be used to clean-up site. Check “Yearly Renewal” if the applicant has a
waste tire hauler registration issued by the Department and include the waste tire hauler registration number.
Check to indicate
if you are a “Self-hauler” or if you are a “Hauler-for-Hire”. All “Haulers-for-Hire” must submit Proof of Financial Assurance in the
amount of $10,000 in order to obtain their Hauler’s Permit.
Type or print:
Name of the waste tire hauler’s business and name of the waste tire hauler requesting the registration and the business
address, E-mail address and telephone numbers.
Mailing address if different from the business address.
Home address and phone number.
Drivers license of the applicant/owner of the company.
List the South Carolina Counties served or if the entire State check “All”.
Certification Statement and Notary: In the presence of the Notary, the applicant must read the Certification Statement,
sign, and date the certification statement, and have it notarized.
Part II: Certification by Waste Tire Collection Facility, Landfill or Processing Facility:
The applicant must have the authorized agent of the waste tire collection facility, landfill, processing facility or facilities complete
and sign. These facilities must be permitted or approved by the Department to receive waste tires.
When the application is completed, the applicant shall mail it to the following address and should retain a copy for their records:
SCDHEC – BLWM
ATTN: Waste Tire Hauler Registration
Division of Compliance and Enforcement
2600 Bull Street
Columbia, SC 29201-1708
Office Mechanics and Filing:
The Division of Compliance and Enforcement will securely file and retain the original registration. File retention is three years from
the termination date of the registration.
DHEC 2735 (11/2015)
Page 3 of 3
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