New Mexico Scrap Tire Manifest

STATE OF NEW MEXICO SCRAP TIRE MANIFESTManifest No. ______

New Mexico Environment Department, Solid Waste Bureau, P.O. Box 5469, Santa Fe, New Mexico 87502-5469, (505) 827-0559

1. GENERATOR INFORMATION AND CERTIFICATION

______(____)______

Generator (Business Name)Contact NameTelephone Number

______

Street AddressMailing AddressCity, State, Zip Code

______Passenger Tires: #______or Weight ______[ ] Pounds [ ] Tons (check one)

Name of Final Destination

Truck Tires: # ______or Weight ______[ ] Pounds [ ] Tons (check one)

Has the generator been charged for the service? [ ] Yes [ ] No (check one)

I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.

Printed Name: ______Generator/Representative Signature: ______Date: ______

2. HAULER INFORMATION AND CERTIFICATION

______(____)______

Company NameContact NameTelephone Number NMED Hauler Registration No.

______

Street AddressMailing AddressCity, State, Zip Code

I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.

Printed Name of Driver: ______Driver’s Signature: ______Date: ______

3. SECOND HAULER (if applicable) INFORMATION AND CERTIFICATION

______(____)______

Company NameContact NameTelephone Number NMED Hauler Registration No.

______

Street AddressMailing AddressCity, State, Zip Code

I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.

Printed Name of Driver: ______Driver’s Signature: ______Date: ______

4. TIRES REMOVED BY HAULER FOR RESALE / REUSE

______(____)______

Company NameContact NameTelephone Number

______

Street AddressMailing AddressCity, State, Zip Code

Passenger Tires Removed: # ______or Weight ______[ ] Pounds [ ] Tons (check one)

Truck Tires Removed: # ______or Weight ______[ ] Pounds [ ] Tons (check one)

I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.

Printed Name of Driver: ______Driver’s Signature: ______Date: ______

5. FINAL DESTINATION

______(____)______

Company / Facility NameContact NameTelephone Number Permit or Registration No.

______

Street AddressMailing AddressCity, State, Zip Code

Passenger Tires Received: # ______or Weight______[ ] Pounds [ ] Tons (check one)

Truck Tires Received: #______or Weight ______[ ] Pounds [ ] Tons (check one)

Weight of Mixed Load of Passenger/Truck______[ ] Pounds [ ] Tons (check one)

I affirm that the information provided above is truthful and accurate. I am aware that falsification of this manifest may result in enforcement action.

______

PrintedName of RepresentativeSignatureDate