WASTE TIRE MANIFEST S tate Form 47273 (R 2/10-06) Indiana Department of Environmental Management INSTRUCTIONS: 1. Use of this form is required by 329 IAC 15-4-13 and IC 13-20-14-5. 2. The Waste Tire Transporter must complete this form for each shipment of waste tires. 3. Fill in all information. Generator, transporter, and receiving facility information may be pre-printed. 4. Give a copy of this form to the generator (source) of the waste tires. 5. Give a second copy of this form to the receiver of the waste tires as listed in IC 13-20-14-4. 6. Keep a copy of this form for your records for at least one (1) year. 7. For help with this form contact IDEM’s Office of Land Quality, Solid Waste Permits Section, at (317) 232-0066. GENERATOR (SOURCE OF W ASTE TIRES) Name Telephone (including area code) Address Generator’s Authorized Agent City State Zip Code Print Name Signature DESCRIPTION OF SHIPM ENT Pickup Date Time Tire Types and Amounts G Passenger tires Pickup Location G Truck tires • Load Type (check one) G W hole Tire Count G W eight in Pounds G Volume Cubic Yards G W eight in Tons G Oversize tires • G Other tires • • TRANSPORTER Name Telephone (including area code) Address Permit/Registration No. City State State Zip Code I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE WAS PICKED UP AT THE SITE DESCRIBED ABOVE AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE. Driver's Name Signature DESTINATION Name Telephone (including area code) Address Permit/Registration No. City State State Zip Code I CERTIFY, UNDER PENALTY OF PERJURY AS PROVIDED IN IC 35-44-2-1, THAT THE MATERIAL DESCRIBED ABOVE HAS BEEN ACCEPTED AND, TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS TRUE AND ACCURATE, AND THAT I AM AN AUTHORIZED AGENT OF THE REGISTRANT. Name of Authorized Agent Signature Receipt Date American LegalNet, Inc. www.FormsWorkflow.com