Form 10304 "Whole Used or Scrap Tire Manifest" - Texas

What Is Form 10304?

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

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Texas Commission on Environmental Quality;
  • 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 fillable version of Form 10304 by clicking the link below or browse more documents and templates provided by the Texas Commission on Environmental Quality.

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Download Form 10304 "Whole Used or Scrap Tire Manifest" - Texas

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Whole Used or Scrap Tire Manifest
TEXAS COMMISSION ON ENVIRONMENTAL QUALITY
1. GENERATOR INFORMATION AND CERTIFICATION:
2. TRANSPORTER INFORMATION AND CERTIFICATION:
Company Name
Date and Time of Pickup
Registration Number/Type of Generator
Registration Number
Driver’s License Number
Print Name:
Telephone Number (###-###-####)
Signature:
Company Name
3. SECONDARY TRANSPORTER INFORMATION AND
CERTIFICATION:
Street Address
City
State
Zip
Company Name
No. of Whole Passenger Tires
No. of Whole Truck Tires
Registration Number
Driver’s License Number
Has the generator been charged for the service?
Print Name:
Yes
No
I certify that the information provided above is true and correct. I am
Signature:
aware that falsification of this manifest may result in suspension,
revocation, or denial of renewal of my generator registration.
By my signature I certify that the information provided above is true and
correct and that only wastes in item 1 of this manifest are contained in
Print Name:
this load. I am aware that falsification of this manifest may result in
suspension, revocation, or denial of renewal of my transporter
Signature:
registration.
ADJUSTMENT BOX
Location and intended use of removed tires:
# of Tires Picked Up:
Passenger Tires
Truck Tires
# Tires Removed for Reuse:
4. PROCESSOR INFORMATION AND CERTIFICATION:
5. STORAGE/DISPOSAL SITE INFORMATION & CERTIFICATION:
Registration Number
Date and Time of Pickup
Registration Number
Date and Time of Pickup
OR
OR
No. Passenger Tires
No. Truck Tires
Weight of Tires (lbs)
No. Passenger Tires
No. Truck Tires
Weight of Tires (lbs)
Telephone Number (###-###-####)
Telephone Number (###-###-####)
Company Name
Company Name
Street Address
Street Address
City
State
Zip
City
State
Zip
I certify that the information provided above is true and correct and that I have been authorized by the Texas Commission on Environmental Quality to
accept whole used or scrap tires for storage, processing, or disposal. I am aware that falsification of this manifest may result in enforcement action.
Signature:
Signature:
Print Name:
Print Name:
Important: a copy of each transaction must be retained by each party for a period of three years. The end use or disposal facility operator must mail the
original completed manifest back to the generator. Following each transaction, the copy separated from the manifest should be the bottom copy.
Green – Generator; Yellow – Transporter; Blue – Processor; Pink – Disposal Facility; White (original signature page) – Generator
TCEQ-10304 (Rev. 07/2019)
Page 1 of 1
Whole Used or Scrap Tire Manifest
TEXAS COMMISSION ON ENVIRONMENTAL QUALITY
1. GENERATOR INFORMATION AND CERTIFICATION:
2. TRANSPORTER INFORMATION AND CERTIFICATION:
Company Name
Date and Time of Pickup
Registration Number/Type of Generator
Registration Number
Driver’s License Number
Print Name:
Telephone Number (###-###-####)
Signature:
Company Name
3. SECONDARY TRANSPORTER INFORMATION AND
CERTIFICATION:
Street Address
City
State
Zip
Company Name
No. of Whole Passenger Tires
No. of Whole Truck Tires
Registration Number
Driver’s License Number
Has the generator been charged for the service?
Print Name:
Yes
No
I certify that the information provided above is true and correct. I am
Signature:
aware that falsification of this manifest may result in suspension,
revocation, or denial of renewal of my generator registration.
By my signature I certify that the information provided above is true and
correct and that only wastes in item 1 of this manifest are contained in
Print Name:
this load. I am aware that falsification of this manifest may result in
suspension, revocation, or denial of renewal of my transporter
Signature:
registration.
ADJUSTMENT BOX
Location and intended use of removed tires:
# of Tires Picked Up:
Passenger Tires
Truck Tires
# Tires Removed for Reuse:
4. PROCESSOR INFORMATION AND CERTIFICATION:
5. STORAGE/DISPOSAL SITE INFORMATION & CERTIFICATION:
Registration Number
Date and Time of Pickup
Registration Number
Date and Time of Pickup
OR
OR
No. Passenger Tires
No. Truck Tires
Weight of Tires (lbs)
No. Passenger Tires
No. Truck Tires
Weight of Tires (lbs)
Telephone Number (###-###-####)
Telephone Number (###-###-####)
Company Name
Company Name
Street Address
Street Address
City
State
Zip
City
State
Zip
I certify that the information provided above is true and correct and that I have been authorized by the Texas Commission on Environmental Quality to
accept whole used or scrap tires for storage, processing, or disposal. I am aware that falsification of this manifest may result in enforcement action.
Signature:
Signature:
Print Name:
Print Name:
Important: a copy of each transaction must be retained by each party for a period of three years. The end use or disposal facility operator must mail the
original completed manifest back to the generator. Following each transaction, the copy separated from the manifest should be the bottom copy.
Green – Generator; Yellow – Transporter; Blue – Processor; Pink – Disposal Facility; White (original signature page) – Generator
TCEQ-10304 (Rev. 07/2019)
Page 1 of 1