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10%�—'^-D5 08:30 LOF GLASS LATHROP y 004 <br /> 5"01•IiWO(91f7 A6V 4(844) aox 842764 �✓/1��f <br /> RAMENTO.GA N0111-2764 STATE OF CAUFnAl IA <br /> DOARD OF EDUAI.IZATION <br /> (910l,32S4555 <br /> HAZARDOUS WASTE DISPOSAL. FEE RETURN BOARD USE ONLY <br /> bUE ON OR BEiFORE RM RR PR <br /> 10/31;/94 FOR JULY - SEPTEMBER, 7994 <br /> Tn AUb Nn <br /> Mail To: HWCA Rv. WD3 3494 HA11HQm36-009011 II Orr, I -pn-r a, <br /> 3'fATE BOARD OF EOUALIZATION <br /> ENVIRONMENTAL FEES DIVISION RISK MGMT-ENVIRONMENTAL AFFAIRS r c <br /> PO BOX 942764 LIBBEY-OWENS-FORD COMPANY <br /> SACRAMENTO CA 94281.276,4 ATTEN: JON WEISS <br /> 500 E.LOUISE AVE PLANT 1 <br /> LATHROP CA 95330 READ INSTRUCTIONS <br /> 500 E.LOUISE AVE PLANT 1, LATHROP BEPOAE PREPARING <br /> CAD005415633 Make oherges n name <br /> er addloae to incona4 <br /> i <br /> OATEOORMa " a O 17 <br /> (Darinla0ns ondl bwh TOTAL TONNAGE TAxAoLE TONNARE FEE RATE AMOUNT <br /> i DISPO9Ea OF (Round Up to OF Fff <br /> i aV OATEOM 'whew tan) {OpumR e■C) <br /> I. Recycled (excludes used oil removed ham a motor 1. - - - - - _ <br /> vehicle) �/ <br /> ?a O <br /> ivl- <br /> 2a.Non-RCRA regulated hazardous wbste (generally 2a. <br /> inolapes astlaclos) D?w <br /> 2b.Non-RCR- .r 3ulsted hazardour wilskevenemIad 2b <br /> In a aaenup salon(a,wP)r1e6'asimstac) . :�,,:,•�:ic.'0):I .:. i91 <br /> 3. Min(ng waste %:ii;:::;;::: te• <br /> 3. a� <br /> 4. ExlFemely hazardous waste 4. <br /> S. Restricted waste <br /> I � <br /> 0, Hazardous wastes <br /> 7. Transported out of slate 7, =j <br /> •'.LTA <br /> S. Residues from incineration or dachjorinallon B. <br /> of hazardous waste 5.36 <br /> 9. Total tae /add times T#trough 8 in Folamn DI 9. <br /> 1�3. 8D <br /> 10. Pw51'Y jmulllply lime 9 by 10%(.10 if payment is made after due date indicated above] PENALTY 10. <br /> I1. INTEREST DF 10% PEIj ANNUM (0.008333 PER MONTH) INTEREST 11 <br /> IS DUE IF PAYMENT IS MADE AFTER THE DUE DATE. <br /> 12.TOTAL AMOUNT DUE AND PAYABLE (sled lines Q,To, auto'17) 12. $/Vd. aO <br /> I herebyoanky tFIa4(Ulie Istuml inducting any accuroan)nn9 eohodui95 arc stelemmrds, has bean - <br /> examinlx!by n*MP to the bast of my knowledge ano bellel ie a Kee,["reel and M10eie rehan. <br /> 1'MNrI YMNAIAE?97GT17 E rwA <br /> We {,s �wi fel _ zoz <br /> A6.rr....14. .0 �-..-. FA .- ' <br />