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11!07;'95 17:35 0209 467 1426 0 B R INC. IA002 <br /> S I A i E OF CAiL1KJRdIA <br /> 8 07 i`11�7 151r� REV.� (3Aa) a� a r-Ay_275d POARD OF FIOUALIZATION <br /> . (9167�1-9655 <br /> RDARQ USE DNLY <br /> HAZARDOUS WASTE DISPaSAL FEE RETURN �� R I" <br /> DUE ON OR BEFORE 7/31/94 FOR JANUARY - JUNE, 1994 TR ALID NR <br /> acco+m}hk. r <br /> Mail To: <br /> H4tCA R111iW03 7194 I1A H 3 055E-89 R� ao P� <br /> STATE BOARD OF EOI_IAU7ATION FILE <br /> ENVIRONMENTAL FEES DIVISION QUICK BRAKE INC. <br /> PO BOX 942754 2325 W. CIIART'ER WAY <br /> SACRAMENTO OA 94291-2754 STOCKTON, CA 95206 <br /> READ 1NSTRUG"fiON$ <br /> 1627 ARMY COURT REFDRE PREPARING <br /> CACU00170109 Make charges ie narna <br /> or address is inmrrect- <br /> A 9 D <br /> CATE(3ilF2lES TOTAL_TONNAOE TA7fABLE TONNAGE FEE RATE Ai CKW <br /> (Dofini#ons M;'nsed) DISPOSED of Q <br /> (Round up to r FuE <br /> e a cl <br /> 8Y GA1ECWY v,,roteter♦) <br /> r led excluQ85 used oil removed from amater - __-_-_ .- } }0::: :: ..... <br /> 1. Re yc t _ <br /> 2a. Non-RGRA fegulated Yiaaardou:waste (generally 2s. <br /> roctudes aQtxrata3) +��' __ <br /> 2b, Non-RGRA rerJuiated ha2afd4u5 wast yruerated 2b. <br /> in a Clear-up action(—Crud"asbestoe) = <br /> 3. Miring weste 3. <br /> 4. Extremely rw2ardous waste a_ <br /> 5. Restrictod waste <br /> 6. HazardOuS WdSte � _ --l}�•��13:' <br /> 7. Transported cart of state <br /> 8_ Residues from inclnerahori Or clechimination $ 5.2q <br /> of hazardous waste <br /> 9. E� <br /> S. Total#ee (add lines t fltroG9118 in Goiurnn D) <br /> 1U. Ponalty [rrrultiuiy line 9 by 10%(.10)if Paymenf is made slier due date Mdk aced above] PENALTY 10. <br /> 11. <br /> INTEREST OF 10% PER ANNUM (0.008333 PER MONTH) [NTMMT 11. <br /> IS DUE IF PAYMENT IS MADE AFTER THE DUE DATE. <br /> 12.T(0)TAL AMOUNT DUE AND PAYABLE {add lines 9,74,and it) <br /> herohy cerft that this return,incluikng arry a=mpanying schoiu106 3XI sta#err►3115.has c�m <br /> ersninad by roe end a tie best❑t Mknowledge and hetet is 9 true, Correct and L'omp� <br /> PRIM7FVPE7 tE AND I I I ' <br /> } <br /> _ F-ECPUA . <br /> Al,yay�write Y00f acmunt number W Vw Ghet*v moncy order. Malmo a mov for wir mmrds. <br />