Form BOE-501-HD Fillable Hazardous Waste Disposal Fee Return

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(enter here and on line 8 of the return the total of the7 Total feeamounts entered in column D) Always write your account number on your check or money order Make a copy of this document for your records $10 08 $123 63 $2 86 $24 98 $3 09 $8 04 (10 PENALTY [multiply line 9 by 10% (0 10) if payment is made after due date shown above] $) (11 INTEREST $) (11 INTEREST: One month's interest is due on the total fee for each month or fraction of a month that payment is delayed after the due date The adjusted monthly interest rate is ) (12 TOTAL AMOUNT DUE AND PAYABLE (add lines 9 10 and 11) $) (7 TOTAL FEE (add the total amounts entered in column D lines 1 through 6) $) (7a Enter in box 7a the total fees included on line 7 that apply to waste generated by a federal government agency 7a $) (8 Total fee from Designated Treatment Technology Waste Schedule (enter from Schedule C line 7 if applicable) (Please see note under Schedule C instructions Filing Requirements ) $) (9 Total fees due (add lines 7 and 8) $) (CATEGORIES 1 Exempt waste Column A WASTE SUBMITTED ) (CATEGORIES 1 Exempt waste Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 2a Non RCRA hazardous waste (generally includes asbestos) Column A WASTE SUBMITTED ) (CATEGORIES 2b Non RCRA hazardous waste generated in a cleanup action (excludes asbestos) Column A WASTE SUBMITTED ) (CATEGORIES 2b Non RCRA hazardous waste generated in a cleanup action (excludes asbestos) Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 3a Hazardous waste not elsewhere classified (RCRA waste) Column A WASTE SUBMITTED ) (CATEGORIES 3b RCRA hazardous waste treated to be a non RCRA Column A WASTE SUBMITTED ) (CATEGORIES 3b RCRA hazardous waste treated to be a non RCRA or nonhazardous waste Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 3c RCRA hazardous waste generated in a cleanup action and treated to be a non RCRA or nonhazardous waste Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 3c RCRA hazardous waste generated in a cleanup action and treated to be non RCRA Column A WASTE SUBMITTED ) (CATEGORIES 4 Mining waste Column A WASTE SUBMITTED ) (CATEGORIES 4 Mining waste Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 5 Extremely and restricted hazardous waste Column A WASTE SUBMITTED ) (CATEGORIES 5 Extremely hazardous waste and restricted hazardous waste 5 Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 6 Solid waste residues resulting from incineration or dechlorination Column A WASTE SUBMITTED ) (CATEGORIES 6 Solid waste residues resulting from incineration or dechlorination Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES 7 Total fee (enter here and on line 8 of the return the total of the amounts entered in column D) Enter in box 7a the amount of fees included on line 7 that have waste generated by a federal government agency 7a $ ) (CATEGORIES Non RCRA 2a Non RCRA hazardous waste (generally includes asbestos) Column A WASTE SUBMITTED FOR DISPOSAL) (CATEGORIES RCRA 3a RCRA hazardous waste or hazardous waste not elsewhere classified Column A WASTE SUBMITTED FOR DISPOSAL) (CLEAR) CLEAR (COLUMN B TONNAGE ACCEPTED FOR DISPOSAL ) (COLUMN B TONNAGE ACCEPTED FOR DISPOSAL ) (COLUMN B TONNAGE ACCEPTED FOR DISPOSAL ) (COLUMN B TONNAGE ACCEPTED FOR DISPOSAL ) (Column B TONNAGE SUBJECT TO FEE (Round column A tonnage to next whole ton)) (Column B TONNAGE SUBJECT TO FEE (Round column A tonnage to next whole ton)) (Column B TONNAGE SUBJECT TO FEE (Round column A tonnage to next whole ton)) (Column B TONNAGE SUBJECT TO FEE (Round column A tonnage to next whole ton)) (column B x C) (Column C APPLICABLE FEE ) (Column C APPLICABLE FEE ) (Column C APPLICABLE FEE ) (Column C APPLICABLE FEE ) (COLUMN D TOTAL FEE (column B x C) $ ) (COLUMN D TOTAL FEE (column B x C) $ ) (COLUMN D TOTAL FEE (column B x C) $ ) (COLUMN D TOTAL FEE (column B x C) $ ) (COLUMN D TOTAL FEE (column B x C) $ ) (Column D TOTAL FEE (column B x C) ) (Column D TOTAL FEE (column B x C) ) (Column D TOTAL FEE (column B x C) ) (Column D TOTAL FEE (column B x C) ) (DATE) (DUE ON OR BEFORE) (EMAIL ADDRESS) (excludes asbestos)a cleanup action2b (FOR BOE USE ONLY ) (Please see note under Schedule C instructions Filing Requirements ) (PRINT NAME AND TITLE) (PRINT) PRINT (TELEPHONE (AREA CODE)) (TELEPHONE) (text) (text) (text) (YOUR ACCOUNT NO ) 1 Exempt waste1 10 Penalty [multiply line 9 by 10% (0 10) if payment is made after due date shownabove]PENALTY10 $ 11 INTEREST: One month's interest is due on the total fee for each month or fraction of a month that 12 TOTAL AMOUNT DUE AND PAYABLE (add lines 9 10 and 11)12 $ 2a Non RCRA hazardous waste(generally includes asbestos) 2b Non RCRA hazardous waste generated in 2b Non RCRA hazardous waste generated ina cleanup action (excludes asbestos) 3a Hazardous waste not elsewhere classified(RCRA waste) 3a RCRA hazardous waste or hazardouswaste not elsewhere classified3a 3b RCRA hazardous waste treated to be 3b RCRA hazardous waste treated to be anon RCRA or nonhazardous waste3b 3c RCRA hazardous waste generated in acleanup action and treated to be anon RCRA or nonhazardous waste3c 3c RCRA hazardous waste generated in acleanup action and treated to be non RCRA 4 Mining waste4 5 Extremely and restricted hazardous waste5 5 Extremely hazardous waste and restrictedhazardous waste5 6 Solid waste residues resulting fromincineration or dechlorination6 7 Total fee (add the total amounts entered in column D lines 1 through 6) 8 Total fee from Designated Treatment Technology Waste Schedule (enter from Schedule C line 7if applicable) (Please see note under Schedule C instructions Filing Requirements )8 $ 9 Total fees due (add lines 7 and 8)9 $ ACCEPTED FORDISPOSALCAPPLICABLE adjusted annual rate established under section 6591 5 of the Revenue and Taxation Code be applicable applies to each ton or fraction thereof of waste disposed of in the state that is a solid hazardous waste residue BOARD OF EQUALIZATION BOE USE ONLY CAPPLICABLE CATEGORIESA Chapter 6 75 (commencing with section 25299 10) or Chapter 6 8 (commencing with section 25300); or generated Class III landfills at which hazardous wastes are disposed of is required to collect the disposal fees from the person or persons Column B For each category round up to the next whole ton the tons shown in column A and enter in column B column D Column D For each category multiply the total tons entered in column B by the rate in column C and enter the total in Control (DTSC) in accordance with Health and Safety Code section 25200 1 5 that DTSC has also designated under Health and DESIGNATED TREATMENT TECHNOLOGY Designated treatment technology is a hazardous waste environmental technology certified by the Department of Toxic Substances DISPOSAL disposal during the period covered by the return Late payments are subject to a penalty of 10 percent (0 10) and interest at an DUE ON OR BEFORE EMAIL ADDRESS Enter in box 7a the amount of fees included on line 7 that have Enter in box 7a the total fees included on line 7 that apply to federal government agency enter in box 7a the amount of fees reported on line 7 for such waste FEEDTOTAL FEE(column B x C) FILING REQUIREMENTS For audit purposes the written evidence should be retained in your files along with the Uniform Hazardous Waste Manifest GENERAL INFORMATION generator or at each specific onsite facility per month Any additional tons in each category are not subject to the fees Generator's BOE account number if the generator is registered HAZARDOUS WASTE DISPOSAL FEE RETURN HAZARDOUS WASTE DISPOSAL FEE RETURN INSTRUCTIONS hazardous wastes in each category disposed of or submitted for disposal in this state at each specific offsite facility by each I hereby certify that this return including any accompanying schedules and statements has beenexamined by me and to the best of my knowledge and belief is a true correct and complete return If any waste is reported at the reduced rate this schedule must be sent with the return Please note: Waste reported on in any other required or voluntary cleanup removal or remediation of a hazardous substance INSTRUCTIONS SCHEDULE C FOR A DESIGNATED TREATMENT TECHNOLOGY WASTE INTEREST11 $ Line 1 Exempt waste Waste submitted for disposal for which the Disposal Fee does not apply received with themanifest and written evidence of exemption The written evidence must meet the above requirements Line 7 Add the total amount of the fees entered in column D Line 7a Waste generated by a federal government agency if any waste submitted for disposal was generated by a Line 8 Enter the total fees from Schedule C Designated Treatment Technology Waste as defined in section 25179 2 of Line 9 Add the total amount of fees on lines 7 and 8 Lines 2b 3c Enter non RCRA or RCRA hazardous wastes generated in a remedial action; removal action or corrective action Make check or money order payable to State Board of Equalization Name of generator non RCRA Non RCRA2a Non RCRA hazardous waste(generally includes asbestos) payment is delayed after the due date The adjusted monthly interest rate is PRINT NAME AND TITLE Pursuant to Health and Safety Code section 25174 6 the fees on lines 2a 2b 3b 3c and 4 apply to the first 5 000 tons of READ INSTRUCTIONSBEFORE PREPARING resulting from treatment of a treatable waste by means of an authorized designated treatment technology resulting from treatment of a treatable waste by means of an authorized designated treatment technology as defined in Health and RETURN PREPARATION Safety Code section 25179 2 Safety Code section 25179 7 as a method which will treat specified types of hazardous waste to substantially reduce or eliminate SCHEDULE C HAZARDOUS WASTE DISPOSAL FEEDESIGNATED TREATMENT TECHNOLOGY WASTE Schedule C should not be reported on lines 1 through 6 on the front of the return schedule do not apply Section 25174 6(a)(7) of the Health and Safety Code specifies that fifty percent (50%) of the disposal fee rate that would otherwise SIGNATURE Signature and printed name of the person making the statementEPA number for the generating site Site address where waste was generated Specific explanation of the reason the waste is exempt from the fee or subject to the cleanup rate STATE OF CALIFORNIA STATE OF CALIFORNIABOARD OF EQUALIZATION SUBJECT TO FEE(Round column A SUBMITTED submitting the waste for disposal and pay the fees to the Board of Equalization (BOE) taken according to Chapter 6 5 (commencing with section 25100) Chapter 6 7 (commencing with section 25280) TELEPHONE Telephone number and address of contact person for the generator the generator of the waste as shown on the originating Hazardous Waste Manifest that the waste is exempt from the fee The the Health and Safety Code To qualify for the reduced rates the waste must be a solid hazardous waste residue the risk to human health and the environment posed by that waste If the waste is treated to be nonhazardous the fees on this The site operator is not required to collect the fee if the person submitting the waste for disposal provides written evidence from third month following the period covered by the return The return must be filed even if wastes were not submitted or accepted for TONNAGE tonnage to next TOTAL FEE Type of waste submitted for disposal Under section 25174 1 of the Health and Safety Code each operator at any facility including but not limited to all Class II and WASTE waste generated by a federal government 7a $been applied toagency waste generated by a federal government agency 7a $ whole ton) written evidence must accompany the manifest and contain the following information: You are required to file a return monthly along with a remittance for any fees due postmarked on or before the last day of the YOUR ACCOUNT NO

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