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state of California—California Environmental r ;tion Agency Qr ns? Go to Frequently Asked Questions at <br /> Department of Toxic Substances Control(DTS.. __aw.dtsc.ca.gov/IDManifest/VQ_FAQ.cfm <br /> P.O. Box 1288 1-877-454-4012(California callers only toll free) <br /> Sacramento,CA 95812-1288 or 1-916-255-4439(local or outside California) <br /> RETURN ALL FORMS WITHIN 30 DAYS ?,() 1 <br /> SCHEDULE A — MANIFEST FEE CALCULATION SHEET FOR_ZGtOMANIFESTS <br /> Refer to instructions on back for more information. <br /> � 1 <br /> EPA ID Number: CAL000306946 Organization Name: <br /> Federal Employer Identification Number(FEIN) REQUIRED `^ <br /> . <br /> Manifest Counts for shipments from January 1, through December 3112M <br /> DTSC recorded the number of manifests Non-Recycled: 1 <br /> at the right for the EPA ID Number shown above. <br /> Recycled: U <br /> If you believe the manifest count above is incorrect, you may use the count from your records. Cross out the <br /> number(s) above and insert your revised number(s). Please note that any difference between the manifest counts <br /> you report and the manifest counts printed on Schedule A is subject to audit by DTSC. <br /> a. Enter the number of non-recycled manifests from above. 0 <br /> b. Enter the number of non-recycled manifests that [ x$3.50 = $ <br /> list only hazardous waste derived from air compliance <br /> solvents. You will determine this number using your records. <br /> DTSC does not have this information for you. <br /> Refer to instructions on back for more information. <br /> c. Subtract the number of manifests listed in Line b. from the manifests listed <br /> In Line a., and enter that number. (Box a— Box b) x $7.50. ©x $7.50 = $ <br /> d. No fee due for recycled manifests. $ 0.00 <br /> (All waste listed on the manifest has a recycling code`.) <br /> e. Total Manifest Fee Due (Add the$Amounts in Lines b. and c.) = $ <br /> The manifest count in Boxes b and c should equal the count in Box a. <br /> Please note that even if you do not owe fees, you are still required to complete and return ALL forms to DTSC. <br /> 'To qualify as recycled, all waste listed on the manifest must be recycled. The hazardous waste disposal facility adds <br /> a code for each waste listed to indicate if it was recycled at their facility. The recycling codes can be found in Box 19 <br /> on the manifest and are H010, H020, H039, H050, or H061. In some cases, the initial receiving facility only transfers <br /> waste to a different facility that may recycle or otherwise handle the waste (1-1141). You can contact your hazardous <br /> waste transporter or disposal facility for more information. If you claim that waste was recycled that is not documented <br /> on a manifest, you are subject to audit and DTSC may ask for additional documentation. Important: Please do not <br /> include your recycling certificates/letters with your Verification Questionnaire and fee assessment forms. Keep these <br /> documents with your manifest records. <br /> DTSC 1194A(4/11) 3 VQ 2011 <br />