Form Stmp St-07 - Tire Fee Report
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1State of Georgia
Environmental Protection Division
STMP ST-07 (Rev. 06/04)
Scrap Tire Management Program
TIRE FEE REPORT
: ______________
Invoice Number
EPD use only
Persons in Georgia that sell new replacement tires must remit $1.00 for each new tire sold to the ultimate consumer. The collected fees are submitted
th
quarterly, along with this report, to the State. This report must be filed and the fee paid by the 30
of the month following the quarter for which the
fee is due in order to avoid loss of dealer's compensation and payment of penalties per the Georgia Comprehensive Solid Waste Management Act,
OCGA 12-8-20, as amended through 1997. All checks should be made payable to the Department of Natural Resources – EPD. DO NOT MAIL
CASH. See note at page bottom for additional information.
I. GENERAL INFORMATION
(please print or type)
Scrap Tire Identification No.:
Calendar Quarter:
Business Name:
Business Address:
Telephone:
Facsimile:
Contact Name:
City:
County:
State:
Zip:
Name, Address, or Ownership Change –
.
Address or Ownership change requires a new application for ID number
New Business Name:
New Business Address:
Telephone:
Facsimile:
Contact Name:
City:
County:
State:
Zip:
II. FEE DEDUCTION CALCULATION
– Enter correct amount due on either Line 3 or Line 7, not both.
1.
Total number of tires sold x $1.00
If Line 1 is $3,000 or less, complete Line 2.
__________
If Line 1 is more than $3,000, go to Line 5.
2.
Take 3% of Line 1 and enter here.
__________
3.
Subtract Line 2 from Line 1 and enter the results here.
(this is the fee you owe)
Total Fees Due
4.
3% of the first $3,000 in fees.
$90.00
5.
Take 0.5% of any fees over $3,000 and enter here.
__________
6.
Add Line 4 and Line 5 and enter the results here.
__________
7.
Subtract Line 6 from Line 1 and enter results here.
(this is the fee you owe)
Total Fees Due
Remit this form and payment to: Tire Fee Report, POB 101902, Atlanta, Georgia 30392
III. CERTIFICATION OF PAYMENT
I/we certify, under penalty of law, that I/we have personally examined and am familiar with the information submitted on
this and all attached documents. I/we believe, warrant, swear or affirm that the submitted information is true, accurate,
and complete.
Authorized Signature:
Print or Type Name & Title:
Date:
NOTE: If you did not sell any tires or paid the $1.00 management fee to your tire distributors during the quarter, you are still
required to file this report with the State. Enter zero on the total fees due line and attach copies of all purchase invoices from
those months. Send the tire fee report and attached invoices (if applicable) to: EPD, Land Protection Branch, 4244 International
Parkway, Suite 104, Atlanta, Georgia 30354, ATTN: Scrap Tire Program. If you have any questions, contact the Scrap Tire
Program at the number below.
Georgia EPD Scrap Tire Management Program 4244 International Parkway Suite 104 Atlanta Georgia 30354 404-363-7027
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