WASTE TIRE COLLECTION CENTER LOG SHEET: Agency Interest #: GOVERNMENTAL ROADSIDE PICKUP R- Facility # Louisiana Department of Environmental Quality Month: Waste Permits Division Year: P.O. Box 4313 Baton Rouge, LA 70821-4313 DATE TIME EMPLOYEE’S NAME STREET: TIRE(S) LOCATION CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME STREET: TIRE(S) LOCATION CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME STREET: TIRE(S) LOCATION CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM TRUCK OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME STREET: TIRE(S) LOCATION CITY: STATE: ZIPCODE: NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE
WASTE TIRE COLLECTION CENTER LOG SHEET: GOVERNMENTAL ROADSIDE PICKUP Louisiana Department of Environmental Quality Waste Permits Division P.O. Box 4313 Baton Rouge, LA 70821-4313 Agency Interest #: Facility # Month: Year: R- DATE TIME EMPLOYEE’S NAME TIRE(S) LOCATION STREET: CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME TIRE(S) LOCATION STREET: CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME TIRE(S) LOCATION STREET: CITY: STATE: ZIPCODE: PHONE NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM TRUCK OFF ROAD EXEMPT SIGNATURE DATE TIME EMPLOYEE’S NAME TIRE(S) LOCATION STREET: CITY: STATE: ZIPCODE: NUMBER LICENSE PLATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM OFF ROAD EXEMPT SIGNATURE
MonthlyWasteTireCollectionCenterReportandLogs2017.docx