AB2398 Request for Payment Survey

Dear applicant for AB 2398 Funds,

Thank you for recycling carpet in the state of California. By doing so, you are contributing to meeting the goals of AB 2398. In order to become eligible for AB 2398 funds, you must complete several steps, including answering this survey. To assist you in completing this survey, please download the worksheet example from the CARE web site.

Completion of the survey does not guarantee the receipt of incentive payments. Please download the Request for Payment Statement from the CARE web site, which you are required to sign, for more information.

To complete the process for applying for funds, you must complete and submit the following documents. If you need additional copies of these documents, please go to the CARE web site.

1. Request for Payment Survey
2. Request for Payment Statement signed by a principal of the business
3. Rolling 12 Month Forecast of Projected Activities

Please note:
1. Incomplete requests will not be accepted.
2. Requests for payment will only be accepted for processed material that has been verified as sold or shipped to a further manufacturer (OUTPUT).
3. Qualified recipients must meet all regulations to operate a business in their state.
4. Recipients must verify that the carpet processed was diverted from California landfills. Records must include:
a. Bills of lading
b. Weight tickets or other functional documents verifying the amount of carpet diverted in pounds from the state of California landfills
c. Copies of Invoices showing that the processed post-consumer carpet was sold or shipped to a further manufacturer.
5. Recipients must submit a signed Request for Payment to CARE, within 60 days of the last day of the quarterly reporting period. The first reporting period for AB 2398 will be July 1, 2011-September 30, 2011. Therefore, all requests are due no later than November 30, 2011.

Completion of these steps does not guarantee that you will receive funds. CARE and its representatives will be reviewing all requests for payment.

Company and Contact Information(Required.)

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

Please indicate the reporting period for this report:(Required.)

July 1- September 30, 2011

Other (please specify)

To assist you in answering the request for incentive payment, please see the attached flow chart.

Please select the type of company from the list below, based upon the descriptions provided. If your company performs more than one function, check all boxes that apply.(Required.)

Collector - A company that consolidates and temporarily stores recovered commercial and/or residential carpet.

Sorting Facility – A facility that segregates collected carpet into the various backing types (PVC, SBR Latex, etc.) and/or fiber types (e.g., Nylon 6, Nylon 6.6, Polypropylene and Polyester).

Processor - A company or facility that receives post-consumer carpeting (whether handled by a sorting facility or brought directly by a collector) and processes it for use as a feedstock in a manufacturing facility.

Manufacturer - A company or facility that utilizes processed carpeting materials and transforms them into other products, or uses them as raw materials in a manufacturing process.

Please report the number of employees you have in the state of California, who work on post-consumer carpet recovery or post-consumer carpet recycling.(Required.)

Number of Employees at the beginning of the reporting period

Jobs lost

Jobs gained

Number of employees at the end of the reporting period

For purposes of completing this request, please use the following definitions.

Carpet as Alternative Fuel (CAAF): Fuel that has been produced from source-separated, and sorted post-consumer carpet and processed, including (1) extraction of components for recycling if at all possible; and (2) size reduction, shredding, and/or blending with coal fines, etc.

Carcass: The remains of a post-consumer carpet, after fiber is sheared or mechanically removed from the carpet face

Cement Kiln: Cement production facility that may use CAAF as a source of energy and/or as an additive for cement production.

Collection: Any method of consolidating and temporarily storing recovered commercial and/or residential carpet.

Disposal Diversion: Carpet removed from the waste stream that was destined for the landfill or incineration, for the purpose of reuse, recycling, CAAF or waste-to-energy.

Disposal Facility: Facilities that are licensed and permitted to provide final disposal for the specific wastes they accept, including waste-to-energy, incineration, and landfilling.

Entrepreneur: Individual or privately-held company which is not a carpet manufacturer, who actively, collects, sorts, processes or manufactures products made from post-consumer carpet.

Filler: Materials such as calcium carbonate, etc. used in the production of carpet backing.
Incineration: Complete burning of material to ashes, with no energy recovery to reduce waste volume.

Landfilling: Landfilling includes the placement of post-consumer carpet and/or the residuals from a post-consumer carpet management method into a landfill disposal facility

Processing: Preparing carpet material for reuse, recycling, CAAF, WTE, or disposal.

Recycling: Transforming or re manufacturing discarded carpet materials into usable or marketable materials, rather than for landfill disposal, incineration, WTE, CAAF, or reuse.

Reuse: Refurbishing and donating/selling recovered carpet back into the market for its original intended use. The reuse of recovered carpet retains the original purpose and performance characteristics of the carpet.

Rural Community: A community with a population of less than 200,000 people.

Sorting: The method used for segregating collected carpet into the various backing types (PVC, SBR Latex, etc.) and/or fiber types (e.g., Nylon 6, Nylon 6.6, Polypropylene and Polyester).

Source Separation: The process by which carpet is separated/segregated from all other materials at the end of its useful life (or when discarded).

Urban Community: A community with a population of 200,000 or more people.

Waste-to-Energy: Process of recovering thermal energy from solid waste through combustion.

NOTE: The next series of questions include ONLY CARPET FROM THE STATE OF CALIFORNIA

Please indicate how many pounds of California post-consumer carpet you have received from a collector or a sorting facility:

(you may have sorted the material yourself or you may have received sorted material from someone else)

(Required.)

Lbs of post-consumer carpet, received from the state of California, for this reporting period

Lbs of California post-consumer carpet from inventory that was processed for this reporting period

TOTAL lbs of California post-consumer carpet available for processing for this reporting period

Please indicate the percentage (%) break-out of carpet received in the previous question, by fiber type.

Note- Total must equal 100%(Required.)

Nylon 6

Nylon 6,6

Polypropylene

PET

Wool

Other/Combined Fibers

Please provide a percentage (%) break-out of the post-consumer carpet received by product type.

Note- Total must equal 100%

Broadloom Carpet

Modular Carpet Tiles

Please indicate the percentage (%) break-out of post-consumer carpet received from commercial or residential customers.

Note- Total must equal 100%

Commercial

Residential

Unknown/Not Sure

Please estimate, to the best of your knowledge, the percentage (%) of carpet received from urban communities or rural communities.

Rural communities are communities with populations of less than 200,000 people.

Note- Total must equal 100%

Urban

Rural

Unknown/Not sure

Please indicate how many pounds of post-consumer carpet you received from California (See Q5) you have:

(Required.)

Reused

Processed and sold or shipped to Manufacturer (i.e. shredded, sheared, hammer milled)

Sent to Inventory

Sent to Waste-to- Energy

Sent to an Incinerator

Sent to the Landfill

Shipped Whole Carpet to customer outside the state of California

Shipped Whole Carpet to customer outside of the US

Carpet Cushion received and sold or shipped to others

Trash/Debris collected (i.e. metal, foreign objects, etc)

Of the post-consumer carpet that you processed from California, please indicate the lbs of output, by output type, that was sold or shipped to a further manufacturer for this reporting period. OUTPUT types include:(Required.)

Fiber

De-poly” or “chemical component”

Shredded Carpet Tile used for Tile Backing

Filler

CAAF

Cement Kiln

TOTAL lbs processed (equals sum of the above)

Sent to Waste-to-Energy

Sent to Landfills

To calculate the funding you may be qualified to receive, the following funding scenario will be applied:

Fiber will qualify for $0.06/lb
Shredded Carpet tile that goes into tile Backing will qualify for $0.06/lb
Filler will qualify for $0.03/lb
CAAF or Cement Kiln will qualify for $0.03/lb and are limited to no more than 15% of total funding available for the reporting period.

NOTE: Requests for payment will only be accepted for processed material that has been verified as sold or shipped to a further manufacturer (OUTPUT).

Processed material that goes into inventory will not qualify for payment until it is sold or shipped to a further manufacturer.

SEE CERTIFICATION STATEMENT FOR MORE INFORMATION.

Please note that CARE will be reviewing all requests for payment and may make revisions to requests based on the review and auditing process.

Please calculate your estimate of the funding requested using the following formula:

Lbs Processed from Carpet received from California X Funding Available = Funding requested.

Enter the dollar amount of funding requested only.

Example: 1,000,000 lb of fiber X $0.06 = $60,000

Fiber

Shredded Carpet Tile used for Tile Backing

Filler

CAAF

Cement Kiln

TOTAL Amount of Funding Requested

I affirm that the answers provided in this survey are accurate and complete to the best of my knowledge.

Signature and Print Name:

I have submitted the following to CARE. (Note that the Request for Payment Statement and the Rolling 12 month forecast may be downloaded from the CARE web site, www.carpetrecovery.org). (Required.)

Signed Request for Payment Statement

Rolling 12 month forecast

If you would like to print a copy of your survey for your files, you may do so by going to "Tools" and clicking on "Print".