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$Ipto of Culggpla•-Wfornla Enftnmonlcl Peotac6n Agenq Oeneralor infamtatfan 8orvicos Spollon <br /> Qgportment E r6klo Substancoa 4`o`ritroT 1.871-d54•.d012(CaIJ:Galata Only 7o11_FrOe) <br /> PA eax 800 of 1.918=285.4432(OuWde Catlr.) <br /> Sacremon1o,CA96812.08Q6 vhvw,dlsc.oe.pov <br /> EPA 10 NUMBER 1 t MANIFEST FEE OREDITCARD PAYMENT FORM <br /> Plea; e xe#rrn fhaas fcirm o 4f youre:ii� kfng arealfi crW pyrtenf. <br /> To pay-your EPA ID.Number derificidtion tes:andlbr rttanlrest fees by cred)t,0ard,cpmplett ;thf§'form'and: <br /> return It vy)Itj'your.r;pmpleted:Verltica(tan tue <br /> <br /> d4i <br /> 2). f1ptne:on Gjedit.0ard: NA aK t In e: t-PA <br /> Via. <br /> Type ofard . <br /> 0 <br /> `' AMERICAN EXPRESS Q IJISCOIIER R-I MASTERCARD: LIVISA <br /> 4) C'redWCard NumbeP / SHIN 91 t71 :10141812 161 1.i ;.+t' 1r�1 <br /> } Ezplraj[on pate: :l DIOL l I J2 <br /> Mo. Yr; i <br /> �) Total Amount of Fees=Ruing-Paid: $ -1,50 <br /> (Should'match.the m9 nt reported asg and total from rho Fees Summary-Sheet Schedule B) <br /> 7) Sfgriaturo; <br /> (The authorized credit card holder's original signature must be pr'esent Inbrder foryoui payment request to be <br /> prviceS*)- <br /> 8) Telephone Number: <br /> IMPORTANT <br /> IfyQt1 intent to ensure,the conttde.ritiality of your credit oard ItlfermaftQ11:010&ss send.ALL completed <br /> forms with your credit card payment to the address below. <br /> DO NOT 0SE THE?15NVKOPE PROVIDE-p, DO.NOT FAX, <br /> Accounting* Uhl,,-0A 1D <br /> Department of Tozlc-Substances.Coritrot <br /> P'A Box$76 <br /> Sacramento, CA.1351312-Q{17§ <br /> Sy.completing and sigrilnq this 'ohni-you:am,author-azft DTS0 to requast turids fr.0mjhe otedltcard,.cpmpany <br /> yau.have indicated, It.the toOblis d'eniee,by yoVr.Oreditoard coinpahy,t TgC yVlu contact yott and t6'gt?Ire <br /> payment by Aneilie?Wdde'piable means,. <br /> PPI AC:Y'SDATEAWNT: itis lntorliietfaft pt1 thlsTorm is raijuested by the Depvitrrtent of Toklo.Substanccs <br /> Control,Accounfing Unit All.thrortlialion Is.volunfaiy. The p6rptisd of thislntbrmat(oli Is to vodly the aulhenticlly <br /> of the credit card,you wish to Use•to pay,your EPA 1D Mkiber and.Manlrest F00, Follula to:pr'ovldr answers to <br /> ttnyorlhequestions.may cause'yourcrediftard"payR?tifft qui t'tii,bbttpnletr Formore:inT37MAtranoraccess <br /> to this record,,please contact the DTSC Accounting'Will ot.(916)324-3-150 pryouurnay willo to MO address <br /> shown above. <br /> THIS$EC'fIQN FOR DEPARTMENT GSE'ONLY <br /> PRIMARY.IQ-NO: _ CID NO: <br /> APRROVED 0 <br /> NOT APPROVED o <br /> DT80 1246(41...00) <br />