Understanding the importance of the Eqp 5128A form within the scope of Michigan's environmental regulations is crucial for those involved in the disposition of scrap tires. Administered by the Michigan Department of Environmental Quality, particularly within the Office of Waste Management and Radiological Protection, this form plays an essential role in tracking the journey of scrap tires from collection to their final disposal or recycling destination. It is intricately linked with the Scrap Tire Transportation Record Eqp 5128, and together, they constitute a comprehensive reporting system mandated by Part 169, Scrap Tires, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended. Designed specifically for consolidated loads, the Eqp 5128A form ensures that all parties involved—the tire generator, the hauler, and the end user/processor/disposer—maintain accurate records of the movement of scrap tires. This safeguarding process includes detailed certification by the generator about the collection and intended destination of the tires, under stringent legal affirmations regarding the truthfulness and completeness of the information provided. To uphold transparency and accountability, the form stipulates retention and sharing requirements for the form's copies, thus, allowing efficient oversight and enforcement of environmental standards concerning the management of scrap tires in Michigan.
| Question | Answer |
|---|---|
| Form Name | Form Eqp 5128A |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | disposer, submitting, false, DEQ |
Michigan Department of Environmental Quality (DEQ), Office of Waste Management and Radiological Protection
CONSOLIDATED LOAD SCRAP TIRE TRANSPORTATION RECORD
This form provides the information required by Part 169, Scrap Tires, of the Natural Resources and Environmental Protection Act, 1994 PA 451, as amended.
THIS IS THE ONLY FORM APPROVED FOR CONSOLIDATED LOAD USE BY THE DEQ AND IS TO BE USED IN CONJUNCTION WITH
THE SCRAP TIRE TRANSPORTATION RECORD EQP 5128.
This form shall be completed and signed by a scrap tire generator or hauler each time that he provides scrap tires for transportation to another facility. A copy shall be retained by the generator before the hauler leaves his site. The end user/processor/disposer to whom the tires are delivered shall complete
this form upon receipt of the scrap tires, retain a copy for their records, and within thirty (30) days, forward a copy of the completed Scrap Tire Transportation Record with the Consolidated Load Record to the generator. The original copy shall be retained by the hauler.
PART 1: SCRAP TIRE GENERATOR CERTIFICATION
I hereby certify that the below indicated scrap tires were collected in the normal course of business and are destined to be transported to the facility indicated in Part 3 of the Scrap Tire Transportation Record. I certify under penalty of law that the information contained on this form, to the best of my knowledge and belief, is true, accurate, and complete. I am aware that there are significant penalties for submitting false or incomplete information, including the possibility of a fine and imprisonment for knowing violations.
GENERATOR #1 - NAME
PHYSICAL ADDRESS
CITY
STATE
ZIP CODE
PHONE
DATE
SCRAP TIRE GENERATOR AUTHORIZED SIGNATURE
PRINT NAME
NUMBER/WEIGHT/VOLUME OF TIRES
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GENERATOR #3 - NAME |
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GENERATOR #7 - NAME |
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DISTRIBUTION: Original must be retained by the Hauler; Copies must be retained by: 1) Generator; 2) Scrap Tire End User/Processor/Disposer; Scrap Tire End User/Processor/Disposer must within 30 days from receipt of tires send a copy of completed record to the Generator. Additional copies of this page may be attached if more than seven generators contribute to a consolidated load. The number of pages attached must be indicated. Additional information required by the generator and/or hauler may be printed on the reverse. See attached instructions on how to complete this form.
EQP 5128a (9/13)