NOTE: A separate manifest must be completed for each load of picked up at each tire generator. Used Tire Manifest 1. DFA Tire Generator Number: -WST 2. Generator’s Name and Site Address: Generator’s Phone No.: 3. Transporter Company Name: 4. ADEQ Transporter License Number: 5. Used Tire Program Name and Site Address: ADEQ Used Tire Program Identification Number: (If none, enter 0) 6. Quantity of Tires Total Quantity Small Large Large a. Generator Culled (Tires Taken Out) By b. Transporter Received by Used Tire Fee-Paid* Fee-Waived* Fee-Paid* Fee-Paid* Fee-Paid* c. Program 7. Comments: 8. Generator Acknowledgement of Tire Amount Shipped Generator I certify that the tire quantities above are, to the best of my knowledge, true and accurate. Rim removal fees are – assessed in accordance with Act 317. Generator’s Printed/Typed Name Signature Year Month Day 9. Transporter Acknowledgement of Receipt of Tires from Generator Transportor I certify that the tire quantities above were picked up at the generator site listed above and, to the best of my – knowledge, this information is true and accurate. Transporter Printed/Typed Name Signature Year Month Day 10. Used Tire Program Acknowledgement of Receipt of Tires from Transporter Used Tire Program I certify that the tire quantity listed above has been accepted and, to the best of my knowledge, this – information is true and accurate, and that I am an authorized agent of the UTP. Used Tire Program Printed/Typed Name Signature Year Month Day *Refers to whether the UTP is charging the generator a fee or not for the delivered.
Used Tire Manifest 1. DFA Tire Generator Number: -WST 2. Generator’s Name and Site Address: Generator’s Phone No.: 3. Transporter Company Name: 4. ADEQ Transporter License Number: 5. Used Tire Program Name and Site Address: ADEQ Used Tire Program Identification Number: 6. Quantity of Tires (If none, enter 0) Total Quantity Small Large Large a. Generator b. Culled (Tires Taken Out) By Transporter c. Received by Used Tire Program Fee-Paid* Fee-Waived* Fee-Paid* Fee-Paid* Fee-Paid* 7. Comments: 8. Generator Acknowledgement of Tire Amount Shipped Generator – I certify that the tire quantities above are, to the best of my knowledge, true and accurate. Rim removal fees are assessed in accordance with Act 317. Generator’s Printed/Typed Name Signature Year Month Day 9. Transporter Acknowledgement of Receipt of Tires from Generator Transportor – I certify that the tire quantities above were picked up at the generator site listed above and, to the best of my knowledge, this information is true and accurate. Transporter Printed/Typed Name Signature Year Month Day 10. Used Tire Program Acknowledgement of Receipt of Tires from Transporter Used Tire Program – I certify that the tire quantity listed above has been accepted and, to the best of my knowledge, this information is true and accurate, and that I am an authorized agent of the UTP. Used Tire Program Printed/Typed Name Signature Year Month Day NOTE: A separate manifest must be completed for each load of picked up at each tire generator. *Refers to whether the UTP is charging the generator a fee or not for the delivered.
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