E-MAIL: contactmcs@modot.mo.gov
MOTOR CARRIER SERVICES PHONE: 1.866.831.6277 Option 3
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270 FAX: 573.522.6708
FORM WT-1 – APPLICATION FOR WASTE TIRE PERMIT
WARNING: Intentional, reckless, false or misleading statements or signatures on this appli cation and any supporting documents may lead to permit
suspension or revocation and possible State or Federal civil or criminal prosecutions resulting in fines, forfeiture or jail sentence.
SECTION 1. GENERAL INFORMATION
USDOT NO. FEIN/SSN (SSN Sole Proprietor Only)
NAME OF CARRIER
DOING BUSINESS AS (DBA) NAME
PRINCIPAL PLACE OF BUSINESS ADDRESS (Not a PO Box) – STREET CITY STATE ZIP CODE
MAILING ADDRESS (If different from Principal address) – STREET CITY STATE ZIP CODE
MISSOURI TERMINAL ADDRESS (If any) – STREET CITY STATE ZIP CODE
PERSON TO CONTACT CONTACT PHONE NO FAX NO E-MAIL ADDRESS
HOW WOULD YOU LIKE TO RECEIVE YOUR PERMIT? U.S. Mail Fax Email
SECTION 2. REGISTERED AGENT
If the state of your principal place of business (as shown above) is NOT Missouri, you must provide a person’s name and physical address (not a PO
Box) in Missouri where legal documents may be accepted on your behalf.
Name and Address:
SECTION 3. FORM OF BUSINESS
Sole Proprietor Partnership Limited Partnership Limited Liability Partnership Limited Liability Company Corporation Trust
STATE OF ORGANIZATION/INCORPORATION DATE ORGANIZED CHARTER NO
ARE YOU IN GOOD STANDING WITH THE STATE IN WHICH YOUR BUSINESS IS REGISTERED? YES NO
If the company is not required to register with the Missouri Secretary of State, please include a certificate of good standing from the state in which
the business is registered, or a copy of the partnership agreement if the form of business is a Partnership.
NAME OF COMPANY OFFICERS OR PARTNERS (Please Print) TITLE
SECTION 4. AREA TO BE SERVED
INTERSTATE – travel through Missouri when transporting waste tires.
INTRASTATE – you do business within the state of Missouri as part of transporting waste tires.
MISSOURI DEPARTMENT OF TRANSPORTATION
SECTION 5. WASTE TIRE MOVEMENTS
A. AMOUNT OF WASTE TIRES TRANSPORTED PER MONTH: Weight Number
IT IS STRONGLY RECOMMENDED THAT YOU USE THE INSTRUCTIONS PROVIDED WITH THIS FORM AS A GUIDE.
INCOMPLETE OR INCORRECT APPLICATIONS WILL DELAY THE ISSUANCE OF A PERMIT.
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B. HAVE YOU EVER BEEN IN VIOLATION OF SECTIONS 260.270 THROUGH 260.278 RSMO? YES NO
(Answering YES will not result in automatic denial. If you answer NO and it is determined that you have been in violation, your application WILL
be denied.)
IF YES, LIST DETAIL OF THE NOTICE OF VIOLATION NUMBER, COUNTY, CASE NUMBER, DATE, CHARGE(S) AND DISPOSITION OF CASE:
C. LIST DRIVER’S LICENSE INFORMATION OF HAULERS EMPLOYED BY APPLICANT
Driver Name License Number License State
D. LIST ALL RECEIVING FACILITIES
Name Address Phone Number
SECTION 6. REGULATORY LICENSE FEES
APPLICANT’S PAYMENT OF THE REQUIRED NONREFUNDABLE PERMIT FEE OF $100 IS ENCLOSED WITH THIS APPLICATION.
SECTION 7. SAFETY COMPLIANCE & SIGNATURE
Commercial motor vehicle safety regulations apply to motor carriers operating in the transportation of waste tires. For more information
about safety regulations that apply to your operation visit the Safety & Compliance section of our website at www.modot.org/mcs.
Applicant, by signature on and/or delivery of this application to the Missouri Department of Transportation (MoDOT), consents on behalf of
itself and its affiliates (including persons and entities under its control or related to applicant, and all of their agents, employees, drivers,
lessors and lessees of vehicles or drivers, and insurance providers) to be investigated by MoDOT or Missouri Department of Natural Resources
(DNR) (including MoDOT or DNR employees, agents, and cooperating law enforcement or regulatory agencies), in relation to the applicant’s
safety fitness and insurance coverage with respect to motor vehicles and drivers. This consent extends to a search for and recovery of all
evidence relating to compliance with state, federal, and local laws whether located on or off the premises of applicant and whether in the
possession of applicant or any third party. MoDOT or DNR may copy or take possession of any document or item of evidence that may be
found during such search or inspection. Termination of this consent by applicant prior to issuance of a permit to operate shall be grounds for
immediate dismissal or denial of the application.
Under penalty of perjury under the laws of the state of Missouri and the United States of America, the information in this application or
attached hereto is true, correct and complete to the best of my knowledge, I am authorized to sign this application on behalf of the applicant
and the signature below is my own true and correct signature made by me or my legal representative and by no other person.
APPLICANT(S) NAME PRINTED APPLICANT(S) SIGNATURE TITLE DATE
SECTION 8. AUTHORIZED 24-HOUR CONTACT PERSON
NAME MO BAR NO (if applicable) BUSINESS PHONE
STREET ADDRESS FAX NO
CITY STATE ZIP CODE 24-HR PHONE NUMBER
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SECTION 9. DESCRIPTION OF POWER UNITS
(include pickups, vans, straight trucks, tractors, and other power units)
Make
Type
(Tractor, Truck, Box
Truck, etc)
Year
Serial Number
(VIN)
License
Plate
STATE
License
Plate
NUMBER
Company
Unit
Number
Gross Vehicle
Weight
Rating
(GVWR)
Licensed Weight
of Vehicle
(Missouri Weight
Categories)*
* NOTE: Missouri Licensed Weight Categories are – 6,000, 12,000, 18,000, 24,000, 26,000, 30,000, 36,000, 42,000, 48,000, 54,000, 60,010, 66,000, 73,280,
78,000, or 80,000 pounds. If your licensed vehicle weight is different from one of these numbers round up to the nearest weight listed.
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WT-1 FORM INSTRUCTIONS
If you have a permit to transport waste tires and need to add or replace power units fill out a WT-2 – Supplemental Permit Certificate for
Transporting Waste Tires form.
SECTION 2 – GENERAL INFORMATION
USDOT Number A USDOT number is required to transport waste tires in the state of Missouri. A USDOT number can be obtained at
www.fmcsa.dot.gov/registration.
FEIN Number/Social Security Number – An FEIN number is a federal Tax ID number. A sole proprietor who does not have an FEIN number should
enter a Social Security Number.
Name of Carrier This is the Company name or Legal Name registered with the Missouri Secretary of State. This name MUST be the same as the
name registered with the FMCSA and the Missouri Secretary of State’s Office, if applicable. All Limited Partnerships, Corporations and Limited
Liability Companies must register with the Missouri Secretary of State u nless the principal place of business is outside of the state of Missouri and
the company participates in interstate commerce as defined in section 390.020, RSMo. Legal name registrations can be filed on line at
www.sos.mo.gov or by calling 1.866.223.6535.
Doing Business As (DBA) Name – A DBA is a name that a company may use that is different from their legal company name. If using a DBA name, it
MUST be registered with the Missouri Secretary of State unless the principa l place of business is outside of the state of Missouri and the company
participates in interstate commerce as defined in section 390.020, RSMo. Fictitious name registrations can be filed online at www.sos.mo.gov or by
calling 1.866.223.6535.
Principle Place of Business The Principle Place of Business address is the location where the safety records of the company are kept or can be
made available. This must be a physical location, not a PO Box.
Mailing Address – Enter the mailing address if different than the principal place of business address. This address may be a PO box.
Missouri Terminal Address – List the address of any terminal located in the state of Missouri, if applicable.
SECTION 2 – REGISTERED AGENT FOR SERVICE OF PROCESS IN MISSOURI
If the principal place of business is NOT in Missouri the name and address of a process agent based in Missouri where service can be made on the
business MUST be provided. This must be the name of an individual, not an organization, and the address must be a physical location, not a PO Box.
The FMCSA provides a list of some process agents on their website at www.fmcsa.dot.gov/registration/process-agents.
SECTION 3 – FORM OF BUSINESS
A. BUSINESS TYPE – Check the box that represents the type of business. This MUST be the same as the type of business registered with the
Missouri Secretary of State, if applicable. Enter the company date of incorporation, state of incorporation, and state registration number.
B. CERTIFICATE OF GOOD STANDING Indicate if the company is in good standing with the registration state. If not required to register with the
Missouri Secretary of State, a certificate of good standing from the registration state MUST be provided. Partnerships must provide a copy of the
partnership agreement (new license only).
C. COMPANY OFFICERS – List the company’s officers, partners, or members and their titles. This is not required for sole proprietors.
SECTION 4 – AREA TO BE SERVED
INTERSTATE – Check this box if you travel through Missouri when transporting waste tires.
INTRASTATE – Check this box if you do business within the state of Missouri as part of transporting waste tires.
SECTION
5 – WASTE TIRE MOVEMENTS
A. List the approximate number or weight of waste tires transported per month.
B. Select if the company has ever been in violation of section 260.270 through 260.278 RSMo. Answering Yes to this question WILL NOT result in
denial of a waste tire permit. If you an swer No to this question and it is determined that the company has been in violation the application
WILL be denied. More information about these sections can be found at http://revisor.mo.gov/main/OneChapter.aspx?chapter=260.
C. Provide a list of all drivers, along with their license number and state for all haulers employed by the company.
D. Provide a list of all receiving facilities, along with the address and phone number for each location. All receiving facilities must be registered
with the Missouri Department of Natural Resources.
SECTION 6 - REGULATORY PERMIT FEES
The application for a waste tire permit must be accompan ied with the $100 permit fee. This fee is nonrefundable. Checks can be made to Director
of Revenue.
SECTION 7 – SAFETY COMPLIANCE & SIGNATURE
Read this section carefully before signing and submitting the applicati on. The company is bound by commercial motor vehicles safety regulations.
Information about the safety regulations that apply to waste tire permit holders can be found in the Safety & Compliance section of the MoDOT
Motor Carrier Services website at www.modot.org/mcs.
The application must be signed to be accepted . If an individual other than the applicant signs the application, proof of power of attorney must be
submitted. If the applicant is a corporation, an officer of the company or an individual authorized to sign on behalf of the company may sign the
application. A member or manager of an LLC may sign the application as long as the member or manger is authorized to sign on behalf of the LLC as
stated in the articles of incorporation or operating agreement.
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SECTION 8 – AUTHORIZED 24-HOUR CONTACT PERSON
Provide the name, address and phone numbers of the authorized 24 -hour contact person. This portion of the application must include a 24 -hour
contact phone number to be accepted.
SECTION 9 – DESCRIPTION OF POWER UNITS
Provide a description of each power unit to be used under this permit for the transport of waste tires.
Gross Vehicle Weight Rating is defined as the value specified by the manufacturer or manufacturers as the m aximum loaded weight of a single or
combination vehicle.
Licensed Vehicle Weight Rating is the gross weight of the vehicle (power unit) plus the maximum load to be carried or pulled at any one time
allowed by Missou ri law. Review these carefu lly. The licensed weight for Missouri should be one of the following: 6,000, 12 ,000, 18,000, 24,000,
26,000, 30,000, 36,000, 42,000 , 48,000, 54,000, 60,010, 66,000, 73, 280, 78,000, or 80,000 pounds. If your licensed weight is different from those
listed round up to the nearest weight listed.
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