Form EQP 5128A is an important form for businesses that wish to file a claim for tax credits. The form can be used to request information about the amount of credit that has been granted, and to request any money that may be owed back as a result of the credit. The form must be filed within three years of the date that the credit was claimed. It's important to note that businesses should not submit Form EQP 5128A if they have already received a refund because of the tax credit. If you have any questions about filing Form EQP 5128A, or need help completing it, please contact our office for assistance. We would be happy to help you get the most out of your business' tax credits!
| 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
PASSENGER |
TRUCK |
OVERSIZE |
|
|
|
|
|
CUT/SHREDDED
|
GENERATOR #2 - NAME |
PHYSICAL ADDRESS |
|
|
CITY |
|
|
|
|
STATE |
|
|
ZIP CODE |
|
PHONE |
||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DATE |
|
|
SCRAP TIRE GENERATOR |
|
|
|
PRINT NAME |
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
||||||||||||||
|
|
|
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
PASSENGER |
|
TRUCK |
|
OVERSIZE |
|
|
CUT/SHREDDED |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GENERATOR #3 - NAME |
PHYSICAL ADDRESS |
|||
|
|
|
|
|
DATE |
SCRAP TIRE GENERATOR |
|
|
PRINT NAME |
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
CITY |
STATE |
ZIP CODE PHONE |
||||
|
|
|
|
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
|||||
|
PASSENGER |
TRUCK |
|
OVERSIZE |
CUT/SHREDDED |
|
|
|
|
|
|
|
|
|
GENERATOR #4 - NAME |
|
PHYSICAL ADDRESS |
||||
|
|
||||||
|
|
|
|
|
|
|
|
|
DATE |
|
SCRAP TIRE GENERATOR |
|
|
|
PRINT NAME |
|
|
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CITY |
|
|
|
STATE |
|
|
ZIP CODE |
|
PHONE |
|||||||
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
|||||||||||||
|
|
|
|
PASSENGER |
|
TRUCK |
|
OVERSIZE |
|
|
CUT/SHREDDED |
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GENERATOR #5 - NAME |
|
PHYSICAL ADDRESS |
|||
|
|
|
|
|
|
DATE |
SCRAP TIRE GENERATOR |
|
|
|
PRINT NAME |
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CITY |
|
STATE |
|
|
ZIP CODE |
PHONE |
||||
|
|
|
|
|
|
|
|
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
|||||||||
|
PASSENGER |
TRUCK |
|
OVERSIZE |
|
CUT/SHREDDED |
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GENERATOR #6 - NAME |
|
PHYSICAL ADDRESS |
|
|
CITY |
|
|
STATE |
|
|
ZIP CODE |
|
|
PHONE |
||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
DATE |
|
SCRAP TIRE GENERATOR |
|
|
|
PRINT NAME |
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
|||||||||||||
|
|
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
PASSENGER |
TRUCK |
|
OVERSIZE |
|
|
CUT/SHREDDED |
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
GENERATOR #7 - NAME |
PHYSICAL ADDRESS |
|||
|
|
|
|
|
|
|
DATE |
SCRAP TIRE GENERATOR |
|
|
PRINT NAME |
|
|
AUTHORIZED SIGNATURE |
|
|
|
|
|
|
|
|
|
CITY |
STATE |
ZIP CODE PHONE |
|||
|
|
|
|
|
|
|
NUMBER/WEIGHT/VOLUME OF TIRES |
||||
|
PASSENGER |
TRUCK |
|
OVERSIZE |
CUT/SHREDDED |
|
|
|
|
|
|
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)