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Application No.: <br /> (OFFICIAL USE ONLY) <br /> COUNTY OF HAWAI`I - DEPARTMENT OF ENVIRONMENTAL MANAGEMENT <br /> Solid Waste Division - Derelict/Abandoned Vehicle Section <br /> 345 Kekuanao`a Street, Suite 41 Hilo, Hawaii 96720 <br /> Tel: (808) 961-8552 • Fax: (808) 961-8553 <br /> r,ww..Ih�,awaiiizeirowas-te..�![gll clle/au�oirmiolive <br /> VEHICLE DISPOSAL ASSISTANCE PROGRAM — APPLICATION <br /> APPLICANT INFORMATION (Please print legibly): <br /> Applicant Name(s): <br /> Phone: Email: <br /> Property Owner(s) Name (if different from above): <br /> Phone: Email: <br /> VEHICLE INFORMATION (Please print legibly): <br /> Location of Vehicle (Street Address): <br /> License Plate No.: VIN: <br /> Year: Make: Body-Type: Color: <br /> o Do you have a copy of the Certificate of Title stamped PERMANENTLY JUNKED? ❑Yes ❑No <br /> o If you answered NO above, does the vehicle meet the criteria to be deemed derelict under HRS- <br /> 290-8(see instructions for definition)? ❑Yes ❑No <br /> By initialing below the applicant covenants that the vehicle mentioned above meets the criteria to be <br /> deemed a derelict vehicle defined under HRS 290-8. <br /> X <br /> Initial(s) <br /> I am/we are the registered owner or property owner of the vehicle or property <br /> listed above and hereby authorize the County of Hawaii to dispose of the vehicle <br /> listed above. 1/we release the County of Hawaii from any liability or claims on the <br /> vehicle listed above after it has been disposed of. <br /> Signature of Registered Vehicle Owner or Property Owner Date <br /> Signature of Registered Vehicle Owner or Property Owner Date <br /> Page 3 of 3 Revised 01-09-2025 <br />