NCT03428_20200511_Application

NC DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES RECENED
DIVISION OF WASTE MANAGEMENT
Scrap Tire Hauler Registration Application MAY B 2020
The following is required by state law in order to obtain a Scrap Tire Hauler Identification Number and approval to
1. Scrap tire hauler status: New t' SECTION
Renewal Current ID #NCT
2. Business name of Hauler: yr jC ®,- OF LIA Phone #: (Q to
3. Owner of Hauler Service: _VI Se. 0
4. Contact Person (if different from owner):
5. Mailing address of Hauler: fS l-i kT
se, '
City: k County: r, w State: /i.0 zip:t
61 _
6. Federal Employer Identification (FEID) number of Hauler: t 4 7 '% Z 3
If no FEID, list hauler's social security number
7. Counties to be served: R c i c k
8. Are you a "For Hire" scrap tire hauler? Yes No
9. List all facilities where you will take scrap tires or processed tires for disposal or recycling
(attach additional sheets if necessary)
Name
County
vv 1sw/ie k If l"7 2 Q1- Le, N.G
Pvn c w+ r GT 2 YLI "X2.
Address
10. Number of vehicles to be used: 1
11. Please submit the following information for each vehicle you will use to transport scrap tires. If you
are using more than one vehicle, attach additional sheets to provide the information for each vehicle.
a. Description of vehicle: O
b. License plate number of vehicle: _L . Zg 4 7 _W
c. Department of Motor Vehicles registration number or VIN #: H �-
d. Name of registered vehicle owner: �A i lr„,, ,Jt� D-% a u_ I k
Si afore of Scrap Tire Hauler
Mail completed form to:
Pam Moore, Solid Waste Section,1646 Mail Service Center, Raleigh, NC 27699-1646
k R.G02.