Waste Tire Transporter Application Form



[pic] |Waste Tire Transporter

Application | |Business Information (please print) Office use only

|Business name: |      | | |

|Address: |      | |ID Number |

|City/State/Zip: |      | |Issue Date |

|County: |      |Phone: |      | | |

|Owner name: |      |Contact name: |      |

|Owner phone: |      |Contact phone: |      |

Has anyone in the company been involved in the transporter program before? Yes No

Vehicle Information (include truck, trailers, and any other vehicle used to haul waste tires)

|Vehicle description |License number |Registered owner |

|      |      |      |

|      |      |      |

|      |      |      |

|      |      |      |

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|      |      |      |

Drivers (include known drivers who will be hauling waste tires)

|Driver name |Driver’s license number (Class A, B, or C) |

|      |      |

|      |      |

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Minnesota Department of Transportation (MNDOT)/Interstate Commerce Commission (ICC) Operating Authority

|MNDOT Intrastate |      | |ICC Interstate |      |

|Authority Number: | | |Authority Number: | |

Disposal Sites

List all sites you intend to use for waste tire disposal. Transporters must transport all waste tires to waste tire facilities, whether within or outside the state of Minnesota that: a) have a permit or have received explicit written approval by the State in which they are located to process, transfer, or store waste tires; or b) businesses which are exempt from any permit requirement related to waste tires.

NOTE: For out-of-state sites, applicant must enclose a copy of the permit or written approval from the appropriate environmental agency in that state verifying the status of the site(s).

|Name |Address |County |State |

|      |      |      |      |

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|      |      |      |      |

|      |      |      |      |

Tire Quantity Estimate (amount collected each season)

| |Spring |Summer |Fall |Winter |

|Passenger/Light truck: |      |      |      |      |

|Oversized tires: |      |      |      |      |

Collection Area (Give a brief description of the boundaries for the area to be served.)

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Return completed form to:

|Solid Waste Permits Unit | |

|Minnesota Pollution Control Agency | |

|520 Lafayette Road North | |

|St. Paul, Minnesota 55155-4194 | |

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