WASTE TIRE COLLECTION LOG SHEET Agency Interest #: Louisiana Department of Environmental Quality R- Facility # Waste Permits Division Month: P.O. Box 4313 Year: Baton Rouge, LA 70821-4313 EMPLOYEE DATE TIME WITNESS INDIVIDUAL’S NAME STREET: MAILING ADDRESS CITY: STATE: ZIPCODE: DRIVER’S PHONE NUMBER LICENSE STATE NUMBER LICENSE PLATE STATE NUMBER MEDIUM NUMBER OF TIRES COLLECTED PASSENGER TRUCK OFF ROAD EXEMPT ELIGIBLE INELIGIBLE How were the tire generated? SIGNATURE EMPLOYEE DATE TIME WITNESS INDIVIDUAL’S NAME STREET: MAILING ADDRESS CITY: STATE: ZIPCODE: DRIVER’S PHONE NUMBER LICENSE STATE NUMBER LICENSE PLATE STATE NUMBER MEDIUM NUMBER OF TIRES COLLECTED PASSENGER TRUCK OFF ROAD EXEMPT ELIGIBLE INELIGIBLE How were the tire generated? SIGNATURE EMPLOYEE DATE TIME WITNESS INDIVIDUAL’S NAME STREET: MAILING ADDRESS CITY: STATE: ZIPCODE: DRIVER’S PHONE NUMBER LICENSE STATE NUMBER
WASTE TIRE COLLECTION LOG SHEET 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 WITNESS INDIVIDUAL’S NAME MAILING ADDRESS STREET: CITY: STATE: ZIPCODE: PHONE NUMBER DRIVER’S LICENSE STATE NUMBER LICENSE PLATE STATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM TRUCK OFF ROAD EXEMPT ELIGIBLE INELIGIBLE How were the tire generated? SIGNATURE DATE TIME EMPLOYEE WITNESS INDIVIDUAL’S NAME MAILING ADDRESS STREET: CITY: STATE: ZIPCODE: PHONE NUMBER DRIVER’S LICENSE STATE NUMBER LICENSE PLATE STATE NUMBER NUMBER OF TIRES COLLECTED PASSENGER MEDIUM TRUCK OFF ROAD EXEMPT ELIGIBLE INELIGIBLE How were the tire generated? SIGNATURE DATE TIME EMPLOYEE WITNESS INDIVIDUAL’S NAME MAILING ADDRESS STREET: CITY: STATE: ZIPCODE: PHONE NUMBER DRIVER’S LICENSE STATE NUMBER
WasteTireCollectionCenterLogSheet.docx