Form Deq-Eurr - Virginia Waste Tire Program End User Reimbursement Application
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2VIRGINIA WASTE TIRE PROGRAM
END USER REIMBURSEMENT APPLICATION
(FORM DEQ-EURR)
No. 152
May 2016 (revised)
COMPANY NAME ________________________________________________________________
ADDRESS _____________________________________________________________________
CITY ________________________________________STATE _______ ZIP ______________
FEDERAL ID# _________________________________________________________________
CONTACT PERSON ____________________ PHONE _____________ Email ______________________
______ Current Flow Waste Tires: End User
_______ Certified Tire Pile Waste Tires:
eligible for $15 per ton reimbursement
End User eligible for $100 per ton
OR
with completed application.
reimbursement with completed application
and DEQ Tire Pile #_________.
NAME AND SITE LOCATION OF END USE ___________________________________________________
VENDOR/SOURCE OF PROCESSED WASTE TIRE MATERIAL _____________________________________
DESCRIPTION OF BENEFICIAL USE (use page 2 for full description response) ___________
USE OCCURRED BETWEEN (DATES)____________________AND__________________________
VIRGINIA-ORIGIN DOCUMENTED BY _______________________________________________
(ATTACH SUMMARY DOCUMENT LISTING WTCS, SCALE TICKETS, OR OTHER RECEIVING RECORD)
COMPLETE THE CALCULATION FOR PURCHASE PRICE (PP) OR COST OF USE (COU)
PURCHASE PRICE CALCULATION
COST OF USE CALCULATION
TONS OF MATERIAL PURCHASED___________________
COST OF USE PER TON__________________
PURCHASE PRICE PER TON_______________________
MINUS TIPPING FEE____________________
NET COST OF USE______________________
TONS OF MATERIAL USED________________
P.P/C.O.U. DOCUMENTED BY ____________________
CERTIFICATION:
I certify that the amount of waste tire material listed above was utilized in the
manner specified on this request during the period listed.
I further certify that the
documentation exists at the office of the company listed above that demonstrates that waste tire
material was from waste tires that were Virginia -generated as defined in the Waste
Tire End User
Reimbursement Regulations (9 VAC 20-150-10 et seq.).
Additionally, I certify that records exist
in our office, for review by DEQ, that shows the purchase price paid or cost of use
and the amount
of waste tire material that was used.
All EUR documentation must be saved for 5 years.
I certify
that I am authorized to sign this application on behalf of the company listed above.
RETURN FORM TO VIRGINIA DEQ
Signature _______________________________Date__________________
P.O. BOX 1105, RICHMOND, VA 23218
FOR DEQ USE ONLY
USE
TONS
RATE
AMOUNT OF REIMBURSEMENT DUE
_____________
_____________
_____________
____________________________________
APPROVED FOR PAYMENT PROCESSING___________________________
DATE_________________
TRANS
AGENCY
GLA
FUND
FFY
PROGRAM
OBJECT
REVENUE
AMOUNT
PROJECT
SOURCE
FUND
DET
PROG
SUB
ELE
PROJECT
TK
PH
COST
FIPS
PSD
AGENCY REFERENCE
INVOICE
DUE DATE
REFERENCE DOC
√
CODE
DATE
NUMBER
MM
DD
YY
NUMBER
SX
DESCRIPTION
CURRENT DOCUMENT
SUBSIDIARY
MULTI-
ACCOUNT
PURPOSE
NUMBER
SX
WASTE TIRE END USER
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