Michigan Department Of Environmental Quality, Waste And Hazardous Materials Division 284 Deq Whmd Stp Eqp5133 251265 7
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PLEASE NOTE: COMPLETE EACH AND EVERY FIELD ON THE APPLICATION. ANY APPLICATION WITH MISSING INFORMATION WILL BE RETURNED AS ADMINISTRATIVELY INCOMPLETE. EQP 5133 (Rev. 12/17) YEAR 2018 FOR DEQ USE ONLY Michigan Department of Environmental Quality Waste Management and Radiological Protection Division Date Received by DEQ: SCRAP TIRE HAULER REGISTRATION APPLICATION Registration is required under authority of Part 169, Scrap Tires, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended. Failure to comply with the provisions of Part 169 may result in fines and/or imprisonment. FOR ADDITIONAL INFORMATION, CONTACT THE SUSTAINABLE MATERIALS MANAGEMENT UNIT, 517-284-6588 WDS #: Received by: Bond Received? Yes No SCRAP TIRE HAULER REGISTRANT Applicant Name (business or person who owns the hauler – this is to whom the Registration will be issued) Michigan Corporate ID Number (required) Telephone Number Email Address (required) Mailing Address City State Zip Physical Address City State Zip County Contact Person Contact Phone Commercial Hauler for Hire? (Check One) Yes No Compliant scrap tire processor? (Check One) Yes Type of Bond (in the amount of $10,000): No (Check One) Surety Bond Cash Bond Irrevocable Letter of Credit Certificate of Deposit Exempt (compliant processor owned/operated hauler) COUNTIES FROM WHICH TIRES ARE COLLECTED. Enter county names. Attach additional pages if necessary. COLLECTION SITES/LANDFILLS USED BY HAULER THE PREVIOUS YEAR, 2017. List registration numbers or license numbers; If site is not registered or licensed, or out-of-state, list address and phone number of facility. Attach additional pages, if necessary. LEGAL DESTINATION TO WHICH THE HAULER WILL TRANSPORT TIRES IN THE CURRENT YEAR, 2018. A PERSON SHALL DELIVER A SCRAP TIRE ONLY TO, AND ONLY WITH THE CONSENT OF THE OWNER OR OPERATOR OF, ONE OF THE FOLLOWING LOCATIONS THAT ARE IN COMPLIANCE WITH PART 169: A COLLECTION SITE REGISTERED UNDER PART 169; A LOCATION THAT HAS LEGALLY ACCUMULATED SCRAP TIRES BELOW THE REGULATORY THRESHOLD AS QUALIFYING AS A COLLECTION SITE; A DISPOSAL AREA LICENSED UNDER PART 115; AN END USER; A SCRAP TIRE PROCESSOR; OR A TIRE RETAILER. List registration numbers or license numbers of COMPLIANT SITES. If site is out-of-state, list address and phone number of facility and provide documentation of home state’s approval. If the site is exempt from registration as a collection site, list the basis for exemption. Attach additional pages if necessary. COLLECTION EQUIPMENT. List all vehicles used. Attach additional pages if necessary. If rental vehicle(s) provide name, address, and phone number of rental company. Vehicle I.D. Number Description (Year and Make) License Plate Number SCRAP TIRES DELIVERED AND COLLECTED BY THE APPLICANT IN MICHIGAN DURING 2017 *(if out-of-state hauler, please indicate if the tires hauled were into or out of Michigan)* 1. Number of scrap tires delivered to Registered Collection Sites during 2017: 1 Ton = 89 PTEs Tons Tires (PTEs) 2. Number of scrap tires delivered to Sanitary Landfills during 2017: Tons Tires (PTEs) 3. Number of scrap tires delivered to other locations during 2017: Tons Tires (PTEs) 4. Total number of tires delivered during 2017: Tons Tires (PTEs) I, the undersigned scrap tire hauler, swear and affirm, UNDER PENALTY OF LAW, that the statements contained herein are true and correct and that the removal, transportation, and disposal of scrap tires will be performed in accordance with the requirements of Part 169. I certify under penalty of law that the information contained on this form, to the best of my knowledge and belief, is true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and imprisonment. SIGNATURE (CHECK ONE) OWNER AGENT . IF AGENT IS CHECKED, DOCUMENTATION FROM OWNER THAT AGENT IS AUTHORIZED TO SIGN FOR THE OWNER MUST BE PROVIDED. PRINT NAME ____________________________________________________________ DATE ____________________________________ SIGNATURE ____________________________________________________________ SEE INSTRUCTIONS FOR COMPLETING THIS APPLICATION ON THE BACK OF THIS PAGE EQP 5133 (Rev. 12/17) INSTRUCTIONS FOR COMPLETING SCRAP TIRE HAULER APPLICATION ALL FIELDS MUST BE COMPLETED, OTHERWISE APPLICATION WILL BE RETURNED AS ADMINISTRATIVELY INCOMPLETE. PLEASE SUBMIT AN ORIGINAL, SIGNED APPLICATION. SCRAP TIRE HAULER REGISTRANT INFORMATION: Applicant name: Enter the legal name of the partnership, corporation, association, governmental entity, or other legal entity making the application for registration as a scrap tire hauler, and any assumed name (i.e., “doing business as” or “DBA”) under which the scrap tire hauler business is to be conducted or transacted. If applying as an individual, a common name for your business may be included in parentheses next to your own name for reference purposes, i.e.: “John Doe (dba XYZ Tires).” NOTE: This is to whom the Registration will be issued. Michigan Corporate ID Number: You must enter the six digit corporate ID number (ID) assigned by the Department of Licensing & Regulatory Affairs Corporation Division. This is NOT your tax ID number. If you do not have a corporate ID number, you must register under your own name and write “individual” in the Michigan Corporate ID Number space. NOTE: Municipally owned facilities do not have a corporate ID Number. Please enter N/A or “Municipality” for these. Email address: You must enter a valid Email address where you may be contacted. Future communications from the Scrap Tire Regulatory Program will be sent via electronic mail. Mailing Address: Enter the address where correspondence should be sent. Physical Address: The address of the business location site even if the same as the mailing address. If there is no actual address for the business location site, please provide a plat map that indicates the location. Commercial Hauler for Hire: If you remove tires for other entities and want to be on the DEQ Web Site as a commercial hauler for hire, please check the “yes” box. If you do not remove tires for other entities or do not wish to be on the DEQ Web Site, please check the “no” box. Bond: A scrap tire hauler shall maintain a bond in favor of the DEQ, unless the scrap tire hauler is owned and operated by a scrap tire processor in compliance with Part 169. The bond shall be on a form approved by the DEQ and shall be in the amount of $10,000. The bond may be in the form of a surety bond, a certificate of deposit, an irrevocable letter of credit, or a cash bond and must be on a DEQ form. Appropriate bond forms are available on the DEQ website or by contacting this office or your DEQ District Office (see the Information Sheet available on the DEQ website.) You must provide documentation that the hauler is bonded with your registration application. Please check the box for the type of bond you are providing. County: List the county in which your facility is located. If out-of-state, provide documentation that hauler is approved to haul scrap tires in Michigan. Contact Person: Enter name of person to contact if questions on the application or operation arise. Contact Phone Number: Enter the phone number of the contact person even if it is the same as facility phone number. COUNTIES FROM WHICH TIRES ARE COLLECTED: List all Michigan counties from which you will be removing scrap tires. If you do not know at this time where you will be removing tires, please indicate all or upper/lower peninsula. COLLECTION SITES/LANDFILLS USED BY HAULER IN THE PREVIOUS YEAR, 2017: List registration or license numbers for all sites to which you delivered tires during 2017. List the name and addresses of any other site that is not a registered collection site or landfill. LEGAL DESTINATION TO WHICH THE HAULER WILL TRANSPORT TIRES IN THE CURRENT YEAR, 2018: Section 16902 states: “A PERSON SHALL DELIVER A SCRAP TIRE ONLY TO, AND ONLY WITH THE CONSENT OF THE OWNER OR OPERATOR OF, ONE OF THE FOLLOWING THAT IS IN COMPLIANCE WITH THIS PART: A COLLECTION SITE REGISTERED UNDER PART 169; A LOCATION THAT HAS LEGALLY ACCUMULATED SCRAP TIRES BELOW THE REGULATORY THRESHOLD AS QUALIFYING AS A COLLECTION SITE; A DISPOSAL AREA LICENSED UNDER PART 115 (WHOLE TIRES MAY NOT BE DISPOSED OF IN A LANDFILL); AN END USER; A SCRAP TIRE PROCESSOR; OR A TIRE RETAILER.” List registration numbers of registered, compliant collection sites or license numbers of permitted and licensed landfills. If site is located out-of-state, list address of facility and provide documentation that the site is approved for operation in their home state. If site is exempt from the collection site registration requirements of Part 169 of the NREPA, list the basis for the exemption. For example, a retailer with less than 1,500 scrap tires is not required to obtain a scrap tire collection site registration. If the location to which tires will be delivered changes during the registration year, the registrant is requested to send a letter to the appropriate DEQ District staff (see the Information sheet for a list of District contacts and phone numbers) indicating the change. At least one compliant, legal site of disposal for the tires must be listed for the application to be considered complete. Attach additional pages, if necessary. Scrap tire haulers should contact the DEQ District office to determine if the collection site is a registered facility or its legal status. COLLECTION EQUIPMENT: List all of the vehicles to be used for scrap tire hauling. Indicate the vehicle I.D. number, year and make of vehicle, and license plate number. If vehicles will be leased, please indicate the leasing company’s name, address, and phone number. NOTE: Please see last page of these instructions for important information. SCRAP TIRES DELIVERED AND COLLECTED BY APPLICANT DURING 2017: All boxes must be completed. If no tires were delivered under a certain category, indicate “0.” Please indicate on the application if numbers are reported in tons or PTEs. DO NOT INCLUDE TIRES TRANSPORTED BY OTHER HAULERS. SIGNATURE: The owner or agent must sign the registration application, print the name, and give date of signature. One of the boxes must be checked indicating if the signee is the owner or agent. If agent, documentation must be provided that the agent is authorized by the owner to sign the application. --------------------------------------------No registration fee is required. NOTE: EACH LOAD OR CONSOLIDATED LOAD OF SCRAP TIRES TRANSPORTED IN THE STATE OF MICHIGAN MUST BE ACCOMPANIED BY A COMPLETED SCRAP TIRE TRANSPORTATION RECORD. THE STATE SCRAP TIRE TRANSPORTATION RECORD OR CONSOLIDATED LOAD SCRAP TIRE TRANSPORTATION RECORD FORMS ARE THE ONLY FORMS APPROVED FOR USE. YOU CAN OBTAIN A COPY FROM THE DEQ WEB SITE: http://www.michigan.gov/scraptires. RETURN COMPLETED REGISTRATION APPLICATION TO: SCRAP TIRE REGULATORY PROGRAM WASTE MANAGEMENT AND RADIOLOGICAL PROTECTION DIVISION DEPARTMENT OF ENVIRONMENTAL QUALITY P.O. BOX 30241 LANSING, MICHIGAN 48909-7741 FOR EXPRESS MAIL: 525 WEST ALLEGAN LANSING, MI 48933 EQP 5133 (Rev. 12/17) SCRAP TIRE AND SCRAP TIRE MATERIAL CONVERSION FACTORS One (1) Ton = 89 Passenger Tires (in any form) = 18 Truck Tires (in any form) One (1) Cubic Yard (yd3) = 9 yd3 Passenger Tires = 7 yd3 Truck Tires = 10 Passenger Tires = 2.5 Truck Tires = 40 Shredded Passenger Tires (approximately 2” X 2”) = 63 Crumbed Passenger Tires (20-30 mesh) = 0.1 ton Passenger Tires = 0.14 ton Truck Tires NOTE* 1 Passenger Tire = 1 PTE 1 Semi Truck Tire = 5 PTEs SCRAP TIRE HAULER REGISTRATION NUMBER: Section 16905(2) states: “The scrap tire hauler registration number issued by the department shall be visibly displayed on a motor vehicle transporting scrap tires, whether the scrap tires are transported in or on the motor vehicle or a trailer. The number shall be in block style numerals at least 2 inches high and located on the driver's side of the vehicle but not on a window. The color of the numerals shall contrast with the background vehicle color.” EQP 5133 (Rev. 12/17)
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