WASTE TIRE ABATEMENT GRANT APPLICATION Regional Solid Waste Management Board or Inter-District: d. Telephone Number: a. District Applicant: e. Fax Number: b. Mailing Address: Contact: f. c. City/State/Zip: g. E-Mail: h. $ Total Anticipated Cost for Cleanup: i. Is the project timetable completed and attached? Yes No Site Information: (attach pictures) a. Site Name: e. County : Number of Tires: Auto b. Site Address: f. (Based Upon 10 Tires Truck Per Cubic Yard) Other c. City/State/Zip: g. Latitude: Property Size d. h. Longitude: in Dimensions: i. Tire Pile Dimensions: Length: Width: Height: j. Section, Township and Range: Site Directions from Major k. Intersection: l. Environmental and Safety Concerns: Telephone Name of Site m. q. Operator: Number: n. r. City/State/Zip: Operator Address: Telephone o. Property Owner: s. Number: p. Address: t. City/State/Zip: Project Description: u. Distance from Nearest v. Residence: w. Rural Metropolitan City Limits Type of Area: x. Attach Public Notices of intent to apply for an abatement grant and solicitation of bidders for services. Certification: To the best of my knowledge, I certify the above information provided is true and correct. Signature of Board Chairman Print Name and Title Date
WASTE TIRE ABATEMENT GRANT APPLICATION Regional Solid Waste Management Board or Inter-District: a. Applicant: d. Telephone Number: e. Fax Number: b. Mailing Address: f. District Contact: c. City/State/Zip: g. E-Mail: h. Total Anticipated Cost for Cleanup: $ i. Is the project timetable completed and attached? Yes No Site Information: (attach pictures) a. Site Name: e. County : b. Site Address: f. Number of Tires: (Based Upon 10 Tires Per Cubic Yard) Auto Truck Other c. City/State/Zip: g. Latitude: d. Property Size in Dimensions: h. Longitude: i. Tire Pile Dimensions: Length: Width: Height: j. Section, Township and Range: k. Site Directions from Major Intersection: l. Environmental and Safety Concerns: m. Name of Site Operator: q. Telephone Number: n. Operator Address: r. City/State/Zip: o. Property Owner: s. Telephone Number: p. Address: t. City/State/Zip: u. Project Description: v. Distance from Nearest Residence: w. Type of Area: Rural Metropolitan City Limits x. Attach Public Notices of intent to apply for an abatement grant and solicitation of bidders for services. Certification: To the best of my knowledge, I certify the above information provided is true and correct. Signature of Board Chairman Print Name and Title Date