Orphan Waste Tire Clean-Up Initiative
Reimbursement Form
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This clean-up program is being carried out under the authority
granted to KDHE under K.S.A.65-3424g(c)(3). Reimbursement
based upon availability of program funding and may be terminated at
any time with 60 days notice.
Kansas Department of Health and Environment
Bureau of Waste Management
785-296-1600
www.kdheks.gov/waste
Return to:
Kansas Department of Health and Environment
Bureau of Waste Management
Attention: Kevin Heit
1000 SW Jackson Street, Suite 320
Topeka, KS 66612-1366
Our Mission: To protect and improve the health and environment of all Kansans.
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This program does not allow reimbursement for tire “amnesty” programs or any other public drop-off event.
To receive reimbursement, a county or city must provide written certification that the waste tires were only
accumulated from illegally dumped or abandoned tires.
Tires must be accumulated in a secure central location point owned by the city or county and approved by the Bureau
of Waste Management. Necessary steps should be taken to control mosquitos and other disease vectors.
Reimbursement will be processed on a monthly basis for any tire disposal expenses, when submitted on the one-
page KDHE form along with receipts from the disposal company, within 30 days of disposal.
Claimants must use a KDHE Bureau of Waste Management permitted waste tire transporter and disposal or
recycling facility to receive reimbursement.
All forms must be submitted by May 1
st
per State fiscal year. The State fiscal year runs from July 1 through
June 30.
I do hereby certify that the waste tires identified in this form for which my county/city is requesting reimbursement from the
Kansas Department of Health and Environment (KDHE) were abandoned waste tires that were cleaned up by the county/city
from roadsides, ditches, fields, or other areas, but not dropped off by members of the public at a county or city site, and were
removed by a KDHE permitted waste tire transporter.
Signature Title Date
(IRS) Tax Number
Brief Description of where and how tires were collected
Total number and type of tires collected and associated with this invoice
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Attach copy of invoice from KDHE permitted waste tire transporter
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Total amount requested
OWT210- revised 11/10/16
