Mobile Waste Tire Processor Name

Waste Tire Mobile Process Certificate of Registration Number

Name/Description of the mobile processing location

Waste Tire Certificate of Registration Number associated with location (if applicable)

Street address or property location/description (Do not list P.O. boxes)

City

Zip Code 

County

Beginning date of mobile processing at this location 

Ending date of mobile processing at this location 

Total number of days processing at this location (Note: Do not process waste tires at this location for more than thirty (30) consecutive days). Please contact waste tire staff if this processing will exceed 30 consecutive days.

List all types of equipment that you will use to process waste tires (e.g. shredder, baler, cutter, etc.):

Have you notified the local governing authority, and gained permission to process waste tires at this location? (Choose Yes or No – if you select No, you must contact the local governing authority to gain permission for mobile waste tire processing to occur at the location.)

I certify that the information on this form is, to the best of my knowledge, true, accurate and complete in all respects, and that I am authorized to complete this application on behalf of this facility.

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name, title and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form subjects the signatory to the same responsibilities as a hand-signed form. Per Section 18-8-306, C.R.S., it is a felony to submit false information to a state official.

Mobile Waste Tire Processor Representative Signature: 

Official title

Email address

Phone number (xxx-xxx-xxx)

Date of signature