Monthly New Tire Self Certification Form (WT-9)

New motor vehicle or new trailer tires sold at multiple locations

This is the form for reporting for multiple stores. If you need to report for a single store, please contact Lisa Jeffrey at 303-692-3437 (1-888-569-1831 ext. 3437 toll-free) or send an email to cdphe_wastetirefees@state.co.us.

Retailer of new waste tires information

CDPHE New Waste Tire Fee ID number *

Month you are reporting for *

Year *

Business name

In order to report your tire volumes, please go to the New waste tire fee for multiple location stores webpage for further instructions.

Mailing address *

City or town *

State *

Zip *

Contact person *

Telephone (xxxxxxxxxx) *

This reporting form must be submitted by the 20th of each month, reporting on new motor vehicle or trailer tires sold the previous month.

Reporting

Under 6 CCR 1007-2 Section 10 of the Colorado Regulations Pertaining to Solid Waste Sites and Facilities, any person who aggregates monthly tire fees from multiple stores must report monthly to the department the number of new motor vehicle or new trailer tires sold at each location.

Volume reporting

Total number of your stores / locations that sold new motor vehicle or new trailer tires. *

Is this is an amended return? *

Yes

No

Check here if you no longer sell new tires.

Yes

Check here if no tires sold this period.

Yes

Number of stores included in this return. *

Number of new tires sold (If none, please enter "0" - Do not use decimals.) *

Amount Owed

$0.00

Please attach the Excel spreadsheet from our website with the detailed numbers for each store. *

Method of payment: *

Online

Mail

Certify and sign

I certify that:

1. I have personally examined and am familiar with the information contained in this submittal;
2. The information contained in this submittal is, to the best of my knowledge, true, accurate and complete in all respects; and
3. I am fully authorized to make this certification on behalf of this facility.

Facility Representative (Signature required for mail-in payments) *

Title *

Email address the form will be sent to with payment instructions. *

Please confirm your email *

Submit Date * +

For the purposes of this form, the Colorado Department of Public Health and Environment accepts your typed name and date as an electronic signature equivalent to your valid signature on a paper copy of the form. As such, this electronically completed form bears the same rights and responsibilities as a hand-signed form.

Once your form has been submitted successfully, you will be re-directed to the Waste Tire pay portal.

A copy of the completed form will be sent as an attachment to the contact person at the email address provided. Please retain a copy in your facility files.