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STATE OF P. O. BOX 647\__.� DUPLICATE—KEEP FOR YOUR REG...06 BOARD OF EQUALIZATION <br /> CALIFORNIA SACRAMENTO CA 95803-0647 HAZARDOUS WASTE CONTROL ACCOUNT, <br /> HAZARDOUS WASTE TAX RETURN (FEE) <br /> o - <br /> �w DUE ON OR BEFORE 4 <br /> mm 17/31/9 FOR 4.,F _ JV* 13 <br /> � 3S79 33002 7983 1 HA h 3o—u , b312 <br /> .11 to: <br /> STATE BOARD OF EQUALIZATION <br /> EXCISE TAX UNIT <br /> P. O. BOX 647 <br /> SACRAMENTO CA 95803-0647 I%DY L CTR:"CICS INC. <br /> �0) INDUSTRIAL PARR. CRTV� <br /> $ AVT-CA LA <br /> READ INSTRUCTIONS Make Changes Above If <br /> BEFORE PREPARING :A%r.:6 4 d 1 q_ 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 <br /> whole ton) (Col. 8 x C) <br /> Oa. Recycled 2.5 <br /> Ob. Disposed Out of State Z 2 <br /> RCRA Exempt (Generally includes asbestos and <br /> 1 petroleum based waste) <br /> 2. Mining Wastes 16. 'g <br /> 3a. Extremely Hazardous Surface Impounded 128.7 <br /> E. <br /> 1b. Extremely Hazardous Not Surface Impounded 1.0 1 Z3.7; 128.70 <br /> 4a. Restricted Wastes Surface Impounded 1;_i;.7 <br /> 4b. Restricted Wastes Not Surface Impounded I <br /> 5. Other.(See category definitions) 7 <br /> Hazardous Waste Landfilled(Generally excludes <br /> Be. asbestos and petroleum based waste-See line 1) 64.3? <br /> 6b. Hazardous Waste Landfgrmed by.35 <br /> Be. Hazardous Waste Injection Well ti 4.35 <br /> 6d. Hazardous Waste Surface Impounded 64.35 <br /> 7. Shredder Waste - - <br /> i .. } <br /> Double Lined Surface Impoundment(Restricted Cat- <br /> 8, egory-See category definitions) 6. 4- <br /> 9. Total Tax(ad lines ID through 80) $ 1211.70 <br /> 10. Penalty of 10%(.10) if payment is made after the due date shown above. Penalty <br /> Trtc DJE +i Interest <br /> '2. TOTAL AMOUNT DUE AND PAYABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Add lines 9,10 and 11) $ 128.70 <br /> 1 hereby certify that this return,including any accompanying schedules and statements, has been <br /> examined by me and to the best of my knowledge and lef is a true,correct d complete return. <br /> SIGNATURE vordo:: Sd. duL'_rr Euvirunmer.Ls 11a::gI;t, ��. sty 9 239 - 4444 <br /> ANDTITLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Z. . . . . . . . . . . . . . . . . <br /> MAKE CHECK OR MONEY ORDER PAYABLE TO STATE BOARD OF EQUALIZAT N , PHONE NUMBER <br /> Always Write Your Account Number on Your Check or Money Order �, <br />