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of Wfornla EnAMpmonlyl Peotac6n Agenq Genoralor I . nfamtaUqn 8orvicos Spollon <br />!2A eux 800 Of 1.918=285.4432 (OuWde Caft) <br />Sacremon1o,CA96812-08Q6 vMwd1sc.ca.Uov . . <br />PPA 10NUMBER 1 t MANIFEST FEE ORIEDIT'GARD PAYMENT FORM <br />n <br />To pay -your EPA ID,'Number verification feb:and/brffianlrest fees b 'and: <br />return It willi,your.r�o.rnpl6.tod:Vorill6a((Ori Queitlonnalre(s) and fbe*hddUleS1d'r manifest dsisGs8midhit <br />form(s), if you prefer to -.pay by che.0K, ploase racyple thls;form. <br />oropoY {b,1', r, - 1261m NNW!, - hmd4iS <br />.' <br />2). f1pm.q:qnCred1t.0ard,' NAOxin' , <br />t-PA <br />k Type 61'QW: QAMERIOANEXPRES5 QOISCOV R -1 MASTERCARD: L <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> bsT: <br />:1 �I-oi L _1/_?l <br />Mo. Yr; <br />Ruing -Paid: <br />iq� nt reported as-gtand total <br />tho <br />B) <br />card original signature m -u is_t, be -pr'e s O'n t In bider f o ( yo u i payment request to 05 <br />FAM <br />IMPORTANT <br />If YoQ Want to ensure, the corifidantlWity of your credit caro Worma,tipji: plo4aspq sen <br />dALL-complot9d. <br />forms with your credit card pqyment to the addreu below. <br />DO NOT 0SE-THE 15NVKOPjE PROVIDE -p, DO NOT FAX, <br />Accounting Unit,•EPA lD <br />Department of Tox'1c;Substanc4s Cdfitrbt <br />P'A O.Ox. 876 <br />Sacramento, CA.9501?-PO,76 <br />Sy.completing and slWilnq this - fofi%- Y%am, authorizing DTS0 16 reqobsit tods fmth.thebtedlt 04r0_6ornpony <br />yo,uhay.61)iftat6d, It. the toObll§ d4nled,by yoVuM 6"aO.Y, 0 86 contact you anq.roq <br />Wit card cQmP Yjf(ho q tra <br />paym6nt by:An6lhe?Wdd6p1ab.Ie means, <br />PPIVACY-SrATEAWNT.- The 11161malf6ii on thk form Is tequesto'd by the DqpMmenl of Toxlo.Sybslanccs <br />Control, Accounting Mt. All. Inrarffidlion Is volunrsiy, The p6rptisd of this In6rMalibli fslo voilly 149 aulljont1cfly <br />of the credit card.you wish to (ise• to pay. yoOr EPA 1D Mkibbt and. Man1lest F#0ti Follvr6to:ptovldsonsmlersto <br />--o"Y oftho questions. may causwypurcredif card aYnWr1t7Uq00V _B#dqnWq. <br />to this record,, please contact the DTSC Accounting Uill0 t.(916)324 -31500,y Q��PayWtllotbll)Oaddross <br />shown above. <br />THIS $EC'.TIQN FOR DEPARTMENT USE 'ONLY <br />PAII MARY IQ - NO: CID NO: <br />APPROVE'E! 0 <br />. NOT APPROVED .0 <br />DT80 .1246 (41.00) <br />