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ET-1210-TK FRONT BOARD USE ONLY (01-90) RE PM EFFECTIVE DATE OF PAYMENT STATE BOARD OF EQUALIZATION MO. DAY YEAR DEPARTMENT OF BUSINESS TAXES EXCISE TAX DIVISION TR PET COPY WRCB P.O. BOX 647 SACRAMENTO, CALIFORNIA 95803-0647 (916) 739-5283 6089 ACCOUNT NUMBER pog o uni r SI, JCi�,E:-p}S (-I�L�}t CnrE: DATE: 01/31/90 TY HQ 44024878 STnct-�,7t>,J cr+gE2cfl *NOTICE OF DETERMINATION* � UNDERGROUND STORAGE TANK MAINTENANCE FEE LAW You are hereby notified of an amount due r from you as shown below: IMPORTANT! A B C READ-1N_STRl1.CILQNRU CRE-COMPLETING, Number Of Tank_ Rate-Of-Fee--Fee- -- -Total-- --- oFees Due (Cl AFB) �- 1. As Determined (October 3, 1989). 2 $200.00 $ 400.00 2. Add:Tanks listed as exempt by the Water Board which you have determined are subject to the fee. $200.00 3. Add:Tanks that were not listed by the Water Board but you $200.00 have listed as subject to the fee. 4. Subtract: Incorrectly identified tanks. (-) $200.00 (-) 5. Total number of tanks and fees due as reported. (Add Lines 1, 2, 3, minus Line 4 in Columns A and C) $200.00 $ 6. Penalty of 25% (.25) if payment is made after 3/31/90. $ 7. TOTAL AMOUNT DUE AND PAYABLE. (Add Lines 5 and 6 in Column C) $ "FEES ARE DUE ON OR BEFORE 3/31/90•• GENERAL Senate Bill 299(Chapter 1442,Statutes of 1989) provides that every owner,as of October 3, 1989,of an underground storage tank containing petroleum,who is issued a permit pursuant to Section 25284 of the Health and Safety Code, is required to pay an annual maintenance fee of $200.00 for each tank. The fee is to be collected by the State Board of Equalization (Board) based on permit information provided by the Water Resources Control Board(Water Board). The amount of the fee has been determined based on all the tanks, except chemical tanks,for which you hold a permit. DEFINITIONS "Owner" is the owner,as of October 3, 1989,of an underground storage tank containing petroleum. "Owner" means any person including any city, county,district,agency,or department thereof. "Owner" does not include the state or federal government. "Petroleum" is defined as crude oil,or any fraction thereof,which is liquid at standard conditions of temperature(60 degrees Fahrenheit) and -- pfeosure(14.7 pounds per square inch)-.-- — -- _ _--- -_- INSTRUCTIONS Please refer to the reverse side of this form for a listing of all your tanks(including chemical tanks) as recorded by the Water Board. Please review the list to insure that all tanks for which a fee has been determined have been properly identified. If you disagree with the identification, please report your corrections on the listing. The following instructions apply: AS DETERMINED-The tanks marked in this column were used to compute fees due. ADDS-Place a check in the add column for each additional tank for which the fee is due. These can be either tanks you have added in the spaces provided or tanks already listed for which no fee is indicated as being determined. DELETES- Enter a check for each tank which WAS IDENTIFIED by the Water Board but which you have determined IS NOT SUBJECT ta.;,he fee. You must provide a separate explanation and supporting documentation for each tank you delete. Deletions are subject to review any it found to be improper,you will receive a subsequent billing. Bring total "adds" forward to Line 2 or Line 3 and total "deletes" forward to Line 4 in Column A above. CERTIFICATION: I hereby certify that this determination, including any accompanying listing, and statements, has been examined by me and to the best of my knowledge and belief is true, correct and complete. PRINT/TYPE NAME AND TITLE SIGNATURE PHONE NUMBER DATE MAKE CHECK OR MONEY ORDER PAYABLE TO THE STATE BOARD OF EQUALIZATION Always write your account number on your check or money order. Make a copy of this document for your records.