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State of California–California Environmentall Ptecton Agency Atio s1 Go to Frequently Asked Questions at — Department of Toxic Substances Control(DTSC) www.dtsc.ca.gov/IDManifeaVVCLFAQ,cfm P.O.Box 1288 1-877-454-4012(California callers only toll free) Sacramento,CA 95812-1288 or 1-916-255-4439(local or outside California) . RETURN ALL FORMS WITHIN 30 DAYS SCHEDULE A – MANIFEST FEE CALCULATION SHEET FOR 2010 MANIFESTS Refer to instructions on back for more information. EPA ID Number: CAL000298604 Organization Name: p r I / M 1' r) I A Gt I't Federal Employer Identification Number(FEIN) REQUIRED (Also called a Federal Tax ID) If you do not have a FEIN, please provide your Social Security Number. Manifest Counts for shipments from January 1, 2010 through December 31, 2010 DTSC recorded the number of manifests Non-Recycled: 0 at the right for the EPA ID Number shown above. Recycled: 0 If you believe the manifest count above is incorrect, you may use the count from your records. Cross out the number(s)above and insert your revised number(s). Please note that any difference between the manifest counts you report and the manifest counts printed on Schedule A is subject to audit by DTSC. a. Enter the number of non-recycled manifests from above. 777-1 • b. Enter the number of non-recycled manifests that ®x$3.50= $ JC/ list only hazardous waste derived from air compliance solvents. You will determine this number using your records. DTSC does not have this information for you. Refer to instructions on back for more information. c. Subtract the number of manifests listed in Line b. from the manifests listed In Line a., and enter that number. (Box a–Box b)x$7.50. r—(71 x $7.5D= $ d. No fee due for recycled manifests. $ 0.00 (All waste listed on the manifest has a recycling code'.) (� e. Total Manifest Fee Due (Add the$Amounts in Lines b.and c.) = $ The manifest count in Boxes b and c should equal the count in Box a. Please note that even if you do not owe fees, you are still required to complete and return ALL forms to DTSC. 'To qualify as recycled, all waste listed on the manifest must be recycled. The hazardous waste disposal facility adds a code for each waste listed to indicate if it was recycled at their facility. The recycling codes can be found in Box 19 on the manifest and are H010, H020, H039, H050,or H061. In some cases, the initial receiving facility only transfers waste to a different facility that may recycle or otherwise handle the waste(1-1141). You can contact your hazardous waste transporter or disposal facility for more information. If you claim that waste was recycled that is not documented on a manifest, you are subject to audit and DTSC may ask for additional documentation. Important: Please do not • include your recycling certificates/letters with your Verification Questionnaire and fee assessment forms. Keep these documents with your manifest records. DTSC 1194A(4/11)