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State of California—California Environmental Protection Agency �../ Generator Information Services Section <br /> DE.pattment of Toxic Substances Control 1-877-454-4012(Calif.Callers Only Toll Free) <br /> P.O.Box 806 or 1-916-255-4439(Outside Calif.) <br /> cramento,CA 95812-0806 w .dtsc.ca.gov <br /> EPA ID NUMBER & MANIFEST FEE CREDIT CARD PAYMENT FORM <br /> Do not return this form unless you are making a credit card payment. <br /> To pay your EPA ID Number verification fee and/or manifest fees by credit card, complete this form and <br /> return it with your completed Verification Questionnaire(s) and fee schedules or manifest assessment <br /> form(s). If you prefer to pay by check, please recycle this form. <br /> 1) Company Name: <br /> 2) Name on Credit Card: <br /> 3) TypeofCard: ❑AMERICAN EXPRESS ❑DISCOVER ❑MASTERCARD ❑VISA <br /> 4) Credit Card Number: <br /> 5) Expiration Date: <br /> Mo. Yr. <br /> 6) Total Amount of Fees Being Paid: $ <br /> (Should m ch the amount reported as grand total from the Fees Summary Sheet Schedule B) <br /> 7) Signature: <br /> (The authorized credit card holder's original signature must be present in order for your payment request to be <br /> processed.) <br /> 8) Telephone Number: ( 1 <br /> IMPORTANT <br /> If you want to ensure the confidentiality of your credit card information, please send ALL completed forms <br /> with your credit card payment to the address below. <br /> DO NOT USE THE ENVELOPE PROVIDED. DO NOT FAX. <br /> Accounting Unit, EPA ID <br /> Department of Toxic Substances Control <br /> P.O. Box 876 I <br /> Sacramento, CA 95812-0876 <br /> By completing and signing this form, you are authorizing DTSC to request funds from the credit card company <br /> you have indicated. If the request is denied by your credit card company, DTSC will contact you and require <br /> payment by another acceptable means. <br /> PRIVACY STATEMENT. The information on this form is requested by the Department of Toxic Substances <br /> Control, Accounting Unit. All information is voluntary. The purpose of this information is to verify the authenticity <br /> of the credit card you wish to use to pay your EPA ID Number and Manifest Fees. Failure to provide answers to <br /> any of the questions may cause your credit card payment request to be denied. For more information or access <br /> to this record, please contact the DTSC Accounting Unit at(916) 324-3150 or you may write to the address <br /> shown above. <br /> THIS SECTION FOR DEPARTMENT USE ONLY <br /> PRIMARY ID NO: CID NO: <br /> APPROVED ❑ <br /> NOT APPROVED ❑ <br /> DTSC 1245 (4/09) ila OSP 1011889 <br />