Form Dhec 2738 – Fill Out and Use

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 SCDHEC or on the Waste Tire Rebate List)

Part I: Certification by Retailer or Generator

Retailer/Generator:______________________________________________________________________________________________________

Owner: ________________________________________________________________________________________________________________

Business Address: ______________________________________________________________________________________________________

City: _______________________________________ State: ________ Zip Code: ______________ County: _______________________

Telephone: _____________________________________________________________________________________________________________

Business License Number: __________________________________ SC Sales Tax Number: _____________________________________

Number of tires selected from waste tires for resale (not included below): _________________________________________________

Destination of Waste Tires

Waste Tire Collection Facility, Landfill or Processing Facility: _________________________________________________________________

Business Address: ______________________________________________________________________________________________________

City: _______________________________________ State: ________ Zip Code: ______________ County: _______________________

Telephone: __________________________________

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 II: Certification by Registered Waste Tire Hauler

Waste Tire Hauler: ______________________________________________________________________________________________________

Business Name: ________________________________________________________________________________________________________

Business Address: ______________________________________________________________________________________________________

Business Owner/Operator: ______________________________________________________________________________________________

City: _______________________________________ State: ________ Zip Code: ______________ County: _______________________

Telephone: ____________________________________________________________________________________________________________

SC Sales Tax Number: ______________________ Waste Tire Hauler Registration Number: _____________________________________

Number of tires listed in Part l as selected by the waste tire hauler for resale: _____________________________________________

Storage address of used tires: __________________________________________________________________________________________

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 III: Certification by Waste Tire Collection Facility, Landfill or Processing Facility

(Must be permitted and/or approved by SCDHEC or on the Waste Tire Rebate List)

Waste Tire Collection Facility, Landfill or Processing Facility: _________________________________________________________________

Owner/Operator:: _______________________________________________________________________________________________________

Business Address: ______________________________________________________________________________________________________

City: _______________________________________ State: ________ Zip Code: ______________ County: _______________________

Telephone: __________________________________

SC Permit Number (if applicable): _________________________________________________________________________________________

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

Number of tires listed in Part l as selected by the waste tire hauler for resale: _____________________________________________

Signed: ______________________________________________________________________________ Date: __________________________

Waste Tire Collection Facility, Landfill or Processing Facilities Authorized Representative

Instructions for Completing DHEC 2738

South Carolina Waste Tire Manifest

Used for Waste Tires Hauled to a Waste Tire Collection Facility, Landfill or Processing Facility

Purpose:

This form is used to track and certify that waste tires received from a retailer/generator of waste tires are delivered to a waste tire collection, facility, landfill or processing facility that is permitted and /or approved by the Department or listed on the SCDHEC Waste Tire Rebate List.

Explanation:

Any person engaged in transporting waste tires in South Carolina for the purpose of storage, disposal or processing must use a South Carolina Waste Tire Manifest to track and certify the movement of waste tires from the retailer/generator to the waste tire collection facility, landfill or processing facility. The manifest supports Regulation 61-107.3, Section F.5, which requires waste tire haulers to record and maintain for three years the following: 1) quantity of tires hauled, 2) where and from whom the tires were hauled; and 3) where the tires were deposited. Finally the manifest certifies transportation of waste tires from the retailer/ generator to the waste tire collection facility, landfill or processing facility and ensures that retailer/generator has documented proof that their waste tires go to the designated facility.

Instructions:

Part I: Certification by Retailer/Generator:

The retailer/generator of waste tires shall complete all items on this part of the form.

Type or print:

•Name of the retailer/generator of the waste tires. This may either be the name of the business or, if it is not a business, the name of the person generating the waste tires.

•Owner of the business

•Business address or if it is not a business the home address of the person generating the waste tires.

•Business phone number or if it is not a business the home phone of the person generating the waste tires.

•County where the business is located or if it is not a business the county where the person generating the waste tires is located.

•Enter County or municipal business license and SC Sales Tax number if you have them – if not enter NA.

•Number of used tires for resale selected and removed from the waste tires.

•The number of waste tires to be transported by type (passenger, truck, off-road) and the total number of waste tires to be transported.

•List the name, address and phone number of the waste tire collection facility, landfill or processing facility that will receive the waste tires

•Enter the County and State in the certification statement and sign and date it.

Part II: Certification by Waste Tire Hauler:

The waste tire hauler shall complete Part II of the form. If the waste tire hauler removes tires from those received from the retailer/generator for the purpose of resale as used tires, list the number of used tires removed. These tires are not those listed in Part I above. Provide the storage address for the used tires. Please note that sorting of waste tires at a location other than the retailer/generator requires a waste tire collection permit from the Department.

Part III: Certification by Waste Tire Collection Facility, Landfill or Processing Facility:

The waste tire collection facility, landfill or processing facility shall complete Part III of the form.

After the form is completed the waste tire hauler will provide the completed and signed manifest to the retailer/ generator of the waste tires within 30-days and retain a copy of the completed and signed manifest for their records per Regulation 61-107.3.

Office Mechanics and Filing:

The Division of Compliance and Enforcement will file and retain manifests that it requests from waste tire haulers for matters of compliance and enforcement. File retention is three years from the termination date of the registration.

DHEC 2738 (1/2014)

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