Form Dhec 2738 – Fill Out and Use This PDF

South Carolina Waste Tire Manifest

Used for Waste Tires Hauled to a Waste Tire Collection Facility,

Landfill or Processing Facility

Must be permitted and/or approved by the S.C. Department of Health and Environmental Control (DHEC)

or on the Waste Tire Rebate List

PART 1: CERTIFICATION BY RETAILER OR GENERATOR

Retailer/Generator:__________________________________________________________________________________________________________________________

Owner:_____________________________________________________________________________________________________________________________________

Business Address:___________________________________________________________________________________________________________________________

City:_ _________________________________________________________ State:_________________________________Zip:____________________________________

Telephone:____________________________________________________________ Fax:_ ________________________________________________________________

Amount of Waste Tires Transported

Total Number of Tires:______________________________________________ Number of Passenger Tires:_________________________________________________

Number of Truck Tires:_____________________________________________ Number of Off-road Tires:___________________________________________________

Destination of Waste Tires:___________________________________________________________________________________________________________________

South Carolina-approved Waste Tire Collection Facility, Landfill or Processing Facility

I hereby certify that the above indicated waste tires were collected in the normal course of business in _________________________ County,________________

State of _________________________ and are destined to be transported to the facility indicated above.

Signed:_______________________________________________________________________________________Date:_________________________________________

(Retailer/Generator or Authorized Representative)

PART 2: CERTIFICATION BY REGISTERED WASTE TIRE HAULER

Waste Tire Hauler:___________________________________________________________________________________________________________________________

Waste Tire Hauler Registration Number:________________________________________________________________________________________________________

Business Name:_____________________________________________________________________________________________________________________________

Business Address:___________________________________________________________________________________________________________________________

City:_ _________________________________________________________ State:_________________________________Zip:____________________________________

County:__________________________________________________________ Telephone:________________________________________________________________

S.C. Sales Tax Number:______________________________________________________________________________________________________________________

Number of Tires Listed Above Selected by the Waste Tire Hauler as Used Tires:_ _______________________________________________________________

Storage Address of Used Tires:_______________________________________________________________________________________________________________

City:_ _________________________________________________________ State:_________________________________Zip:____________________________________

I hereby certify that the waste tires received from the retailer/generator (see Part I of this form) will be delivered to the destination designated by the retailer/ generator and that the completed and signed manifest will be returned to the retailer generator within 30 days from this date. I also certify that I will retain a copy of the manifest for my records per Regulation 61-107.3.

Signed:_______________________________________________________________________________________Date:_________________________________________

(Waste Tire Hauler or Authorized Representative)

PART 3: CERTIFICATION BY WASTE TIRE COLLECTION FACILITY, LANDFILL OR PROCESSING FACILITY (Must be permitted and/or approved by DHEC or on the Waste Tire Rebate List)

Waste Tire Collection Facility, Landfill or Processing Facility:______________________________________________________________________________________

Owner/Operator:_ ___________________________________________________________________________________________________________________________

Business Address:___________________________________________________________________________________________________________________________

City:_ _________________________________________________________ State:_________________________________Zip:____________________________________

County:__________________________________________________________ Telephone:________________________________________________________________

S.C. Permit Number (if applicable):____________________________________________________________________________________________________________

I hereby certify that this facility is permitted and /or approved by DHEC to receive waste tires from South Carolina and has received the following amount of waste tires

Amount of Waste Tires Received

Total Number of Tires:______________________________________________ Number of Passenger Tires:_________________________________________________

Number of Truck Tires:_____________________________________________ Number of Off-road Tires:___________________________________________________

Signed:_______________________________________________________________________________________Date:_________________________________________

(Waste Tire Collection Facility, Landfill or Processing Facilities Authorized Representative)

INSTRUCTIONS FOR COMPLETING DHEC 2738

South Carolina Waste Tire Manifest