Form Dhec 2711 – Fill Out and Use This PDF

Business Name: _________________________ Permit #: __________________________

TIRE DISPOSAL

For this section, please list the contact information for all the DHEC PERMITED FACILITIES where tires will be disposed. Include (name of Facility, name of the Operator, Facility address, and phone number and contact information). Please note - the information contained in this section must be accurate and complete for your registration to be accepted. Attach additional sheets if necessary.

Facility______________________________ Address____________________________________________ City, State, Zip__________________________

Phone # __________________ Operator_______________________ Contact Name_________________________ Contact Phone #__________________

Facility______________________________ Address____________________________________________ City, State, Zip__________________________

Phone # __________________ Operator_______________________ Contact Name_________________________ Contact Phone #__________________

Facility______________________________ Address____________________________________________ City, State, Zip__________________________

Phone # __________________ Operator_______________________ Contact Name_________________________ Contact Phone #__________________

Facility______________________________ Address____________________________________________ City, State, Zip__________________________

Phone # __________________ Operator_______________________ Contact Name_________________________ Contact Phone #__________________

I hereby certify (or declare) that all information submitted in conjunction with this registration is true to the best of my knowledge. I am aware that there are significant penalties for submitting false information, including the possibility fines and imprisonment. I certify that I am authorized to sign official documents

for this applicant.

Signature: __________________________________________________ Date ___________________________

Print Name and Title __________________________________________

This registration form will only be processed if it is filled out completely. All future changes to any of this information will require this form to be updated by contacting the Department immediately. Renewal applications must be accompanied by the annual report. All renewal applications must be received annually, prior to March 1st. Main- tain a copy for your records. Submit the original form to the address below. For any questions or to notify the Department of any changes, call (803) 896-4137.

SCDHEC - BLWM, Division of Compliance and Enforcement, 2600 Bull Street, Columbia, SC 29201

DHEC 2711 (01/2011)

Instructions for Completing DHEC 2711

SOUTH CAROLINA WASTE TIRE HAULER REGISTRATION FORM

PURPOSE:

Complete this form in its entirety when applying for a new or renewal registration as a waste tire or processed tire hauler.

EXPLANATION AND DEFINITION:

Any waste tire hauler (based in or outside of SC) engaged in transporting waste tires or processed tires in South Carolina for the purpose of storage, disposal or processing must register with the Department.

For a new registration, the applicant must complete a SC Waste Tire Hauler Registration Form. To renew an existing registration, the hauler must complete the SC Waste Tire Hauler Registration Form and submit the SC Waste Tire Hauler Annual Report along with the registration. Department approved registrations are effective from the date of issuance

until March 1st of the following year. It is the responsibility of the registered hauler to renew annually! A corporate entity or local government may submit one application to register its entire fleet of vehicles.

ITEM BY ITEM INSTRUCTIONS:

•Check NEW if the hauler, is a new hauler. Check RENEWAL if the hauler has a waste tire registration number issued by the Department. Include the waste tire hauler registration number (ID) if this is a renewal registration.

•Print or type:

OName of the hauling company requesting registration

OName of the owner

OCompany’s location-address,

OMailing address information, if different from the business address,

OCounty.

Oe-mail address - if available,

OPhone and fax numbers and

ONumber of Owner’s Valid Drivers License and the name of the state that issued it.

•Complete all the information in the section labeled “TIRE PICK-UP”. Attach additional sheets if needed:

OPlease note that your Registration will not be processed without all of the requested information.

•Complete all the information in the section labeled “TIRE DISPOSAL”. Attach additional sheets if needed:

OPlease note that your Registration will not be processed without all of the requested information.

•Sign and date the registration form then print complete name and title below.

OFFICE MECHANICS AND FILING:

Please mail the original form to: South Carolina - DHEC / L&WM Waste Tire Hauler Registration 2600 Bull Street

Columbia, SC 29201

The applicant should keep a copy of this form for their records. The Division of Compliance and Enforcement will maintain the original registration form in the applicant’s file.

Per the SC Solid Waste Management Regulation R.61-107.3 - Waste Tires - all renewal applications must be must be accompanied by your SC Waste Tire Hauler Annual Report showing all of the tires picked up and disposed of during the months between March 1st of the previous to the end of February of the current year.

As a reminder, if your company is located outside of South Carolina or hauls waste tires outside of South Carolina, please check with the local solid waste authority for area registration and/or hauling information.

DHEC 2711 (01/2011)