EPD Use Only – Project ID#: ______

Local Government Scrap Tire Abatement Reimbursement ApplicationSCRAP TIRE AMNESTY EVENT

I. Applicant Information
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
Eventname (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:
Facility Name / Address / City / Zip
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):
Facility Name / Address / City / Zip
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 epd.georgia.gov/scrap-tires.
Tire carrier name: Permit#:
Tire carrier name: Permit#:
Scrap tire processor name: Permit/Approval#:
Scrap tire processor name: Permit/Approval#:
III. AMNESTY EVENT 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.
All collection/drop-off locations to be used during the amnesty day event:
Facility Name / Address / City / Zip
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):
Facility Name / Address / City / Zip
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 epd.georgia.gov/scrap-tires.
Tire carrier name: Permit#:
Tire carrier name: Permit#:
Scrap tire processor name: Permit/Approval#:
Scrap tire processor name: Permit/Approval#:
IV. aCKNOWLEDGEMENTS / Yes / No / N/A
Permitted tire carriers and permitted/approved processors will be used. / ☐ / ☐ / ☐
Procurement of contractors will follow current city/county procurement policy. / ☐ / ☐ / ☐
Appropriate safety measures will be taken while performing scrap tire abatement. / ☐ / ☐ / ☐
Liability waivers will be completed. / ☐ / ☐ / ☐
If there are any changes in the project after the execution of the agreement, awardee will notify EPD in writing (e.g., estimated cost of project, event date, location of temporary storage/collection sites, carriers/processors). / ☐ / ☐ / ☐
To the best of your ability, scrap tires will not be collected from businesses that generate scrap tires (e.g., retail tire dealers). / ☐ / ☐ / ☐
While awaiting transport to a scrap tire processor, tires will be stored in a manner that is protective of human health and the environment. / ☐ / ☐ / ☐
All scrap tires collected during the event will be removed within 30 days of event date. / ☐ / ☐ / ☐
Final report, reimbursement request, and other required documents will be submitted to EPD within 90 days of event date. / ☐ / ☐ / ☐
V. Authorization
I, the undersigned authorized representative, certify that to the best of my knowledge, the information contained herein is true and correct.
Signature: / Date:
Print name: / Title:
Address: / City: / ZIP:
Mail completed application to: / Georgia Environmental Protection Division - Land Protection Branch
c/o Russell Nix, Waste Reduction Unit Manager
4244 International Parkway, Suite 104
Atlanta, GA 30354 / Questions? Call 404-362-2537
PLEASE ALLOW 30 DAYS
FOR PROCESSING

Rev. 112216