Local Government Scrap Tire Abatement Reimbursement Application SCRAP TIRE AMNESTY EVENT I. INFORMATION County/Municipality/Authority: Federal tax ID#: Project manager (contact for questions about the event Title: or application): Email: Phone: Total estimated # of scrap tires to be collected: Total cost of event(s): $ II. AMNESTY EVENT Event name (e.g., Fall 2016 City/County Scrap Tire Amnesty Day): Date of event: Estimated # of Estimated cost: $ scrap tires to If the date changes after execution of the If it’s determined that the cost will exceed the be collected: agreement, awardee must notify EPD in writing approved amount of funding, awardee must submit of the new date and the reason for the change. a written request to EPD for additional funds. All collection/drop-off locations to be used during the amnesty day event: All locations where scrap tires will temporarily be stored while awaiting transport to a processing facility after the collection event (if different from collection sites listed above): Is the temporary storage site(s) approved/permitted by EPD to store scrap tires? Yes List the approval/permit number(s): – No Site(s) must be approved/permitted by EPD before execution of the contract – Tire carriers and scrap tire processors you plan to use and their permit/approval numbers. For permitted tire carriers and permitted/approved processors, visit . Tire carrier name: Permit#: Tire carrier name: Permit#: Scrap tire processor name: Permit/Approval#: Scrap tire processor name: Permit/Approval#: III. AMNESTY INFORMATION (If more than two events, please attach additional pages.) Event name (e.g., Spring 2017 City/County Scrap Tire Amnesty Day): Date of event: Estimated # of Estimated cost: $ scrap tires to If the date changes after execution of the If it’s determined that the cost will exceed the be collected: agreement, awardee must notify EPD in writing approved amount of funding, awardee must submit of the new date and the reason for the change. a written request to EPD for additional funds.
Local Government Scrap Tire Abatement Reimbursement Application SCRAP TIRE AMNESTY EVENT I. County/Municipality/Authority: Federal tax ID#: Project manager (contact for questions about the event or application): Title: Email: Phone: Total estimated # of scrap tires to be collected: Total cost of event(s): $ II. AMNESTY EVENT INFORMATION Event name (e.g., Fall 2016 City/County Scrap Tire Amnesty Day): Date of event: If the date changes after execution of the agreement, awardee must notify EPD in writing of the new date and the reason for the change. Estimated # of scrap tires to be collected: Estimated cost: $ If it’s determined that the cost will exceed the approved amount of funding, awardee must submit a written request to EPD for additional funds. All collection/drop-off locations to be used during the amnesty day event: All locations where scrap tires will temporarily be stored while awaiting transport to a processing facility after the collection event (if different from collection sites listed above): Is the temporary storage site(s) approved/permitted by EPD to store scrap tires? Yes – List the approval/permit number(s): No – Site(s) must be approved/permitted by EPD before execution of the contract Tire carriers and scrap tire processors you plan to use and their permit/approval numbers. For permitted tire carriers and permitted/approved processors, visit . Tire carrier name: Permit#: Tire carrier name: Permit#: Scrap tire processor name: Permit/Approval#: Scrap tire processor name: Permit/Approval#: III. AMNESTY INFORMATION (If more than two events, please attach additional pages.) Event name (e.g., Spring 2017 City/County Scrap Tire Amnesty Day): Date of event: If the date changes after execution of the agreement, awardee must notify EPD in writing of the new date and the reason for the change. Estimated # of scrap tires to be collected: Estimated cost: $ If it’s determined that the cost will exceed the approved amount of funding, awardee must submit a written request to EPD for additional funds.
Amnesty%20Application.docx