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STATE OF P. O. BOX 647 DUPLICATE-KEEP FOR YOUR RECO.. BOARD OF EQUALIZATION <br /> mm CALIFORNIA SACRAMENTO CA 95803-0647 HAZARDOUS WASTE CONTROL ACCOUNT, <br /> HAZARDOUS WASTE TAX RETURN (FEE) <br /> o _ <br /> mW DUEONORBEFORE 04/3v/89 FOR <br /> JAN _ MAR 33 <br /> u03679 39032 2989 I HA ur 36-00e31Z <br /> Mail to: _ <br /> STATE BOARD OF EQUALIZATION <br /> EXCISE TAX UNIT <br /> P. O. BOX 647 _ <br /> SACRAMENTO CA 95803-0647 INDY EIECTRONIC5 INC. <br /> 40C INDUSTRIAL PARK DRIP <br /> M.A"T*CA CA 45336 <br /> READ INSTRUCTIONS Make Changes Above It <br /> BEFORE PREPARING C AT 04 n 6 4 618 2 Name or Address Incorrect <br /> A B C D <br /> Categories Total Tonnage Disposed Taxable Tonnage Rate of Tax Amount of Tax <br /> (Definitions Enclosed) of By Category (round up to (Col. B x C) <br /> whole ton) <br /> Oa. Recycled 2.3 <br /> Ob. Disposed Out of State -0- 3 2. 1 8 -0- <br /> RCRA Exempt (Generally includes asbestos and <br /> 1 petroleum based waste) -0- 1 b.^4 -0- <br /> 2. Mining Wastes -0- 16. 1s -0- <br /> 3a. Extremely Hazardous Surface Impounded -0- 121 .70 -0- <br /> 3b. Extremely Hazardous Not Surface Impounded -0- 1 Z 3.T 0 -0- <br /> 4a. Restricted Wastes Surface Impounded -0- 12 3.7`e -0- <br /> 4b. Restricted Wastes Not Surface Impounded -0- 1 2 5. 7 Ck -0- <br /> 5. Other.(See category definitions) -0- 3.22 -0- .. <br /> Hazardous Waste Landfilled(Generally excludes <br /> Be. asbestos and petroleum based waste-See line 1) 0.04 1.0 64. 3� 64.35 <br /> 6b. Hazardous Waste Landfarmed -0- 64.35 -0- <br /> 6c. Hazardous Waste Injection Well -0- 64.35 -0- <br /> 6d. Hazardous Waste Surface Impounded -0- 54.35 -0- <br /> 7. Shredder Waste -0- i ��'' -0- <br /> Double Lined Surface Impoundment(Restricted Cat- <br /> B. egory-See category definitions) -0- 6.44 -0- <br /> 9. Total Tax(ad lines ID through 6D) $ 64.35 <br /> 10. Penalty of 10% (.10) if payment is made after the due date shown above. Penalty -0- <br /> 11.15 Ji;t LF MADE 4FIcR T'+E !"SF. CAT:. Interest -0- <br /> 12. TOTAL AMOUNT DUE AND PAYABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Add lines 9. 10 and 111 <br /> 1 hereby certify that this return, including any accompanying schedules and statements, has been <br /> examined by me and t e best of my knowledge and belief is a true,correct and complete retum. <br /> SIGNATURE GorNon W. Butler <br /> AND TITLE EnV1TOpme.ntal. J7Hn3g {'p'!1^. . . 1?::. : . :� . . . . . . . . . . �.209 239 .-. 4444. . . . <br /> MAKE CHECK OR MONEY ORDER PAYABLE TO TE BOARD OF EQUALIZATION PHONE NUMBER <br />