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46 2011 SCHEDULE B-FEES SUMMARY SHEET • (See back of this form for complete instructions.) SECTION A - EPA ID NUMBER VERIFICATION FEE JJJuu�ly 1,20100--June 30,2011) 1. Name of your organization: (Required) !/ ' r l/ / I I n I / � �a r /C 2. Federal Employer Identification Number(FEIN): (R quired) (Also called a Federal Tax ID.) If you do not have a Federal Employer 10 Number,please provide your Social ecurity Number. 3. Total number of persons employed by your organization in California: (See reverse.) For example,if your organization has two California facilities(site 1 has 48 employees and site 2 has 49 employees),the correct EPA ID Fee Rate would be$175 because the total number of California employees is 97. Even if only 1 location deals with hazardous waste,all employees at all California locations are counted. Number of Em to ees 1-49 1 50-74 75-99 100-249 1 250-499 1 500or more EPA ID Fee Rate NO FEE $150 $175 $200 $225 $250 (Total EPA ID Number Verification Fees not to exceed$5000) 4. Enter EPA ID Fee Rate based on total number of persons employed by your organization in California. $ 5. Total number of permanent EPA ID Numbers held by your organization and active at any time 1� during July 1,2010-June 30,2011. Attach a Verification Questionnaire(page 1)and Schedule A for each permanent EPA ID Number in California. Exclude numbers beginning with"CAC"or"CAP". 6- Multiply the$Amount in A.4.by the number in A.S.(Fee rate multiplied by number of EPA ID Numbers). $_ 7. TOTAL EPA ID NUMBER VERIFICATION FEE DUE. (Enter the dollar amount from Line A.6. �y above OR$5000,whichever amount is less.) $ SECTION B - MANIFEST FEE(January 1,2010-December 31,2010) 1. Enter the dollar amount on Line e.from your Schedule A-Manifest Fee Calculation Sheet. If you are reporting more than one EPA ID Number,enter the TOTAL of the dollar amounts in Line e.from all of your Schedule A-Manifest Fee Calculation Sheets, $ 2. Carefully read the instructions listed on the back in Section B.2.before completing this section.If your business has less than 100 employees,the first four non-recycled manifests used in the 2010 calendar year are free. (Manifests listing only waste derived from air compliance solvents are excluded and cannot be claimed as free.) In order to receive the credit,list the manifest tracking number(s)of each of the non-recycled • manifest(s)you are claiming as free. Do not call DTSC for manifest tracking numbers. You must refer to your records;you are required to keep copies of your hazardous waste manifests for 3 years. If you do not have a copy of your manifest(s),contact your hazardous waste transporter to get a copy for your records. Enter manifest tracking numbers(required): (t) (2) (3) (4) 1 manifest=$7.50 credit 1 2 manifests=$15.00 credit 1 3 manifests=$22.50 credit 1 4 manifests=$30.00 credit 3. Enter$credit amount based on number of manifests claimed as free. $ 4. MANIFEST FEE DUE FOR 2010 MANIFESTS(Subtract$in Line B.3.from Line 8.1.) 8.1.-B.3. _ $ SECTION C -GRAND TOTAL OF FPA ID NUMBER VERIFICATION FEES AND MANIFEST FEES Add the$amount in A.7.and the$amount B.4. Enter the total. TOTAL FEE DUE: $ If you do not owe any fees,you are still required to complete and submit all forms. If paying by check,make check payable to DTSC&write one of your EPA ID Numbers on Your check. If you are paying by credit cam,use the enclosed credit card form. I hereby ceHffy under perialtlty of perjury that the information on Schedule A(s)and Schedule /B Is true and correct. c_v Signature of Preparer: �-1 r (Zng.' Z- t-w,.t.� Title: (ft n9 Q !; to /- Name(please print)'I)t! r1 \ K A r� D►1�-H F1� ('{ Date: -a�_1 kojne: ';i'o �-� �Q� -/ �1 PLEASE RETURN THE ORIGINAL OF THE FOLLOWING DOCUMENTS WITHIN 30 DAYS Signed and Dated Verification Questionnaire (one Verification Questionnaire for each EPA ID Number) Y Schedule A-Manifest Fee Calculation Sheet (one Schedule A for each EPA ID Number) g Signed and Dated Schedule B-Fee Summary Sheet (only one Schedule B is needed for your entire organization) PY Payment Due,if any. Please include at least one of your EPA ID Numbers on your check or credit card form. THIS SECTION FOR DEPARTMENT USE ONLY Check No: $AMOUNT DATE: CID NO: . 12560055: 12560092: 12560065: 12560035: 12560091: AMOUNT DUE: 12560075: 12560096: PRIMARY ID#: DTSC 11948-(FRONT)(4/11) VQ 2011