New Submission

1. Applicant Information:

Application Submittal Period:*field type radio button
Application Submittal Period:May 15th - June 15th (for the period of October through March)November 15th - December 15th (for the period of April through September)
County:*field type single line
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Mailing Address:*field type single line
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Address Line 2:field type single line
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City:*field type single line
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State:*field type single line
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Zip Code:*field type single line
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Primary Contact:*field type single line
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Title:*field type single line
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Email:*field type single line
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Direct Phone:*field type single line
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2. Scrap Tire Management Program Tons and Trailer Documentation:

Tons of scrap tires - no disposal fee charged/free (Certified as originated in NC generated in the normal course of business):*field type number
Tons of scrap tires - disposal fee charged/paid:*field type number
Total tons of scrap tires received:*field type number
Contract cost per ton for disposal/processing scrap tires:*field type currency
$
Actual cost per ton for disposal/processing scrap tires*field type currency
$(Invoiced disposal contract cost) / (total tons of scrap tires received)
The average weight in tons of a single scrap tire trailer hauled to the disposal/processing company:*field type single line
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Submit scrap tire trailer documentation:

Use upload attachment button in Section 8 (Upload limited to two documents).
If County uses a scrap tire shredder, see last question in Section 8.

Submit a copy of all scrap tire trailer invoices and tally scrap tire tons and charges on each invoice and list the total scrap tire tons and the total charges for all scrap tire trailer invoices on the last invoice OR

Submit an itemized list of all scrap tire trailer invoices listing the destination(s), dates, disposal/processing company invoice numbers, scrap tire tons, and charges (tally scrap tire tons and charges for each scrap tire trailer invoice and the total scrap tire tons and total charges of all invoices).
Invoice/Itemized list total scrap tire tons:*field type single line
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Invoice/Itemized list total charges:*field type currency
$

3. Scrap Tire Disposal/Processing Costs:

(Average the costs if more than one disposal/processing company is used.)

Do not include costs associated with scrap tire cleanup.
Disposal/processing Company contract cost (do not include fuel and fuel surcharge cost if separate):*field type currency
$
Disposal/processing Company shipping contract cost - if known (do not include fuel and fuel surcharge cost if separate):*field type currency
$
County cost of shipping if it hauls its scrap tires to the disposal/processing Company (do not include fuel cost if separate): Note: Scrap tire hauler registration required.*field type currency
$
Revenue from scrap tire charges (disposal fee amount from scrap tires that do not qualify for free disposal):*field type currency
$Automatically subtracted from total.
Total light load excess charges:*field type currency
$Automatically subtracted from total.
Total dirty tire load excess charges:*field type currency
$Automatically subtracted from total.
Total contractor trailer loading charge:*field type currency
$Automatically subtracted from total.
Total scrap tire disposal/processing cost (Line A):field type currency
$Automatically Calculated.
Number of trailers hauled to the scrap tire disposal/processing company:*field type single line
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Average cost of a single scrap tire trailer hauled to the scrap tire disposal/processing company:*field type single line
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Does the County unload scrap tires brought to the collection site from haulers?*field type radio button
Does the County unload scrap tires brought to the collection site from haulers?YesNo
Does the County require haulers to place scrap tires in its trailers?*field type radio button
Does the County require haulers to place scrap tires in its trailers?YesNoN/A
Does the County store scrap tires on the ground/pad prior to trailer delivery or live load?*field type radio button
Does the County store scrap tires on the ground/pad prior to trailer delivery or live load?YesNoN/A

Scrap Tire Collection Site Container Information:

	Collection Site Name (County/City/Town, Business Location, Etc.):*field type multi line	How Many Container(s)/Equivalent Stacked Tires at this Collection Site:*field type multi line	Type of Container(s) at this Collection Site:*field type multi line	Size of Container(s) at this Collection Site:*field type multi line	Tons of Scrap Tires Collected at this Collection Site:*field type multi line
Row 1×	Collection Site Name (County/City/Town, Business Location, Etc.):*field type multi line	How Many Container(s)/Equivalent Stacked Tires at this Collection Site:*field type multi line	Type of Container(s) at this Collection Site:*field type multi line	Size of Container(s) at this Collection Site:*field type multi line	Tons of Scrap Tires Collected at this Collection Site:*field type multi line	×

Click to Add Another Collection Site and Container Information

How many scrap tire collection sites are located in the County (including municipal, business location(s), convenience sites, etc.):*field type single line
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4. Fuel Costs:

Disposal/processing/collection site finance charge(s)/purchase(s)/rental(s), replacement costs, construction and maintenance, equipment finance charge(s)/purchase(s)/rental(s), equipment depreciation and maintenance, County collection fuel expenses, supervisor, administrative, and scale house wages, employee healthcare and retirement, and uniforms do not qualify for grant monies.
Fuel and fuel surcharges, to include County fuel costs if it hauls scrap tires to the disposal/processing company:field type currency
$(Fuel and fuel surcharges does not include County collection fuel expenses, except for machinery operated at the primary County collection site)
Explanation(s):field type single line
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Total additional disposal/processing costs (Line B):field type currency
$Automatically Calculated.

5. Labor Costs:

Disposal/processing/collection site finance charge(s)/purchase(s)/rental(s), replacement costs, construction and maintenance, equipment finance charge(s)/purchase(s)/rental(s), equipment depreciation and maintenance, County collection fuel expenses, supervisor, administrative, and scale house wages, employee healthcare and retirement, and uniforms do not qualify for grant monies.
Labor Costs:field type currency
$(Labor applies to the equivalent of two full-time employees and the primary County collection site)
Explanation(s):field type single line
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Total additional Program costs (Line C):field type currency
$Automatically Calculated.

6. Scrap Tire Management Program Cost Total and Grant Request:

Total cost to operate the County's scrap tire program (Lines A + B + C):field type currency
$Automatically Calculated.
6(a). NCDOR Scrap Tire Tax Proceeds distributions (Commonly, the latest report should NOT be referenced):*field type drop-down
Distribution Quarter Period #1 Tax Proceeds Distribution:*field type currency
$
Distribution Quarter Period #2 Tax Proceeds Distribution:*field type currency
$
6(b). Total scrap tire disposal tax proceeds distributed from NCDOR during selected 6-month period:field type currency
$Automatically Calculated (Total combined tax proceeds distributed for Quarter Periods #1 and #2).
6(c). Scrap Tire Disposal Account Fund grant amount requested:field type currency
$Automatically Calculated (Total Program costs - Total tax proceeds distributed).
If the number above is negative, the County does not qualify for a grant.
If the County does not qualify for a grant, DO NOT submit this application.

7. Applicant's Primary County Scrap Tire Collection Site Location:

County:*field type single line
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Physical Address:*field type single line
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Address Line 2:field type single line
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City:*field type single line
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State:*field type single line
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Zip Code:*field type single line
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Applicant's primary county collection location GPS coordinates (Decimal Degrees system):*field type geolocation
Use current location or Specify coordinates
Current Location
Specify coordinates
Use current location
Contract Disposal/Processing Company Name(s):*field type single line
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One-way mileage from County's primary scrap tire collection site to the contracted scrap tire disposal/processing company:*field type number

8. Additional Information, Document Upload, and Applicant Certification

Does the County conduct audits of businesses that have trailers paid for by the County?*field type radio button
Does the County conduct audits of businesses that have trailers paid for by the County?YesNoN/A (Only if no trailers located at businesses).
Does the County conduct audits of businesses that have its scrap tires brought to the County collection site?*field type radio button
Does the County conduct audits of businesses that have its scrap tires brought to the County collection site?YesNo
Does the County visit businesses that stockpile scrap tires?*field type radio button
Does the County visit businesses that stockpile scrap tires?YesNo
Does the County conduct audits of third-party contract operators?*field type radio button
Does the County conduct audits of third-party contract operators?YesNoN/A
Does the County shred its scrap tires?*field type radio button
Does the County shred its scrap tires?YesNo
Does the County dispose of shredded scrap tires in a MSW landfill?*field type radio button
Does the County dispose of shredded scrap tires in a MSW landfill?YesNoN/A
If yes, name of MSW landfill:field type single line
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Does the County store shredded scrap tires prior to reuse/sale?*field type radio button
Does the County store shredded scrap tires prior to reuse/sale?YesNo
Does the County plan to obtain a scrap tire shredder?*field type radio button
Does the County plan to obtain a scrap tire shredder?YesNo
If County uses a scrap tire shredder, submit a spreadsheet or documentation using the upload attachment button below, showing:
Tons of scrap tires received,
Tons of scrap tires shredded,
Tons of shredded scrap tires stored,
Tons of whole scrap tires stored,
Tons of shredded scrap tires landfilled,
Tons of whole and shredded scrap tires removed from the site,
And, for what purpose will whole and shredded scrap tires be used after being removed from the site (ex. manufacturing, construction, fuel, etc.)
Additional Information:field type richtext
Document Upload:*field type file upload
Upload limit: 2 Documents
Drop files here
You have reached the maximum file limit: 2.
All scrap tires certified as originated in North Carolina generated in the normal course of business shall be accepted free of charge.
The Scrap Tire Disposal Account Fund Grant application will not be considered if required information is not submitted or the application is incomplete.
I certify that by applying to the Scrap Tire Disposal Account Fund for a grant that the information provided is an accurate description of the County's costs associated with its scrap tire management program.
A copy of this application has been received by the County Finance Officer.*field type checkbox
A copy of this application has been received by the County Finance Officer.Yes
Finance Officer Name:*field type single line
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Finance Officer Title:*field type single line
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Finance Officer email address:*field type single line
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Finance Officer phone number:*field type single line
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Applicant Signature:*field type signature
Applicant Name:*field type single line
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Applicant Title:*field type single line
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Applicant email address:*field type single line
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Applicant phone number:*field type single line
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Date:*field type date
mm/dd/yyyy

Scrap Tire Disposal Account Fund Grant Application

1. Applicant Information:

2. Scrap Tire Management Program Tons and Trailer Documentation:

3. Scrap Tire Disposal/Processing Costs:

Scrap Tire Collection Site Container Information:

4. Fuel Costs:

5. Labor Costs:

6. Scrap Tire Management Program Cost Total and Grant Request:

7. Applicant's Primary County Scrap Tire Collection Site Location:

8. Additional Information, Document Upload, and Applicant Certification