Pitt County Forms Center

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   1717 W. 5th Street Greenville, NC 27834  |  Telephone: (252) 902-1000

   Required North Carolina Scrap Tire Certification for Disposal at Public Collection Facilities

   
   Parts I and II must be completed to qualify for free disposal. Used tires and casings obtained from out-of-state by retreaders or used tire dealers are not eligible for free disposal. County may require proof that tires originated in NC. Used tire dealers, wholesalers, brokers, retreaders, and others who sort, grade, or cull loads of tires which were removed from vehicles by another NC dealer must provide the original certification from the individual who first removed the tire from a vehicle. Tires stockpiled before January 1, 1994 are not eligible for free disposal.

4. Part 1: Certification by Retailer or Other Person Disposing of Scrap Tires

   To be completed by generator.

6. Name of retailer or other person disposing scrap tires.
8. Address
9. Phone Number
11. City
12. State
13. Zip Code
15. How many tires were collected for disposal?
17. Where did these tires originate?
    (County and State)
18. Time Period of Tires
20. I certify that the above information is true to my knowledge.
22. Number of Tires Removed From Vehicles When Replacement Tires Were Sold in NC
    (Provide copies of E500G or E500 tax reports or other documentation if required by county.)
24. Number of Tires Removed When Vehicles Were Repaired or Junked in NC
    (Provide proof of eligibility for free disposal if required by county.)
26. Number of Tires Removed From Fleet Vehicles in NC (e.g. School bus shop, trucking company garage)
    (Provide proof tires were purchased in NC and proof of payment of disposal tax if required by county.)
28. Number of Tires Collected by Means Other Than the Normal Course of Business
    (e.g.Cleanup projects, pre-1994, stockpiles from businesses and junkyards)
29. Fees

    1. Landfill Fees Paid
    2. Fees Waived by County
31. Number of Tires That Originated Out of State
32. Fees

    1. Landfill Fees Paid
    2. Fees Waived by County
34. Signature*
    Must have original signature.
35. Date
    Date
37. Part II: Certification by Scrap Tire Hauler

    To be completed by hauler.

39. Name of Scrap Tire Hauler
41. Scrap Tire Hauler Identification Number
42. Merchant Identification Number (sales tax number)
    (Applies only to retailers hauling their own tires)
44. Mailing Address
45. Phone Number
47. City
48. State
49. Zip Code
51. How many of the same tires that were received from the person disposing of scrap tires in Part 1 of this form and not others did this load contain?
53. I certify that the above information is true to my knowledge.
55. Signature*
    Must have original signature.
56. Date
    Date
58. Part III: Certification by Collector, Processor, or Disposer

    To be completed by collector.

60. Facility Name
61. Number of Tires Received
63. Recieved by Signature
64. Date
    Date
66. Providing False or Incomplete Information On This Form Is Subjec T to a Civil Penalty of Up to $5000 Per Violation Pursuant to N .C.G.S. 130A-22. Falsifying This Report Is a Class 2 Misdemeanor and Subject to a Fine of Up to $10,000 Pursuant to N.C.G.S. 130A-26-2.
    
    This Form Is to Be Retained by the Collector, Processor or Disposer for Three Years.
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