Form 570 Oregon Dry Cleaning Annual Fee Return 2003
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Form
OREGON DRY CLEANING ANNUAL FEE RETURN
Date received
•
570
Tax Year 2003
DUE DATE: JANUARY 1, 2003
SSN/Federal identification number
Business identification number
Program code
Year
Period
Liability
Payment received
•
•
•
•
•
•
570
2003
01
1
Mailing Address
Business Site Address
Telephone number
Do not separate
(
)
Oregon law states you MUST file a return
FEES
SECTION I
Check here if you are a DRY CLEANING FACILITY (If you are a Dry Store, go to Section II)
(A) ANNUAL BASE AND RISK FEES (check all appropriate boxes)
$500
00
1.
Annual base fee ................................................................................................................................... 1
In addition, enter the amount indicated on the line provided. All three may apply.
2.
Did you use Perchloroethylene (Perc) at any time at this facility before 2003?
.................................................................................................................................. 2
Yes (enter $250)
3.
Will you use Perc at this facility during this fee period?
(January 1, 2003 to December 31, 2003)
............................................................. 3
Yes (enter $500)
4.
Will you use any “Other” solvents at this facility during this fee period?
(January 1, 2003 to December 31, 2003)
............................................................. 4
Yes (enter $125)
5.
Total of Section I-A (add lines 1, 2, 3, and 4)..................................................................................... 5
(B) ANNUAL ENVIRONMENTAL FEE (must check appropriate box)
Projected gross receipts (see definition in instructions) for fee period (January 1, 2003 to December 31, 2003). You must enter
the amount indicated on the line provided.
6.
Facilities with gross receipts between $0 and $99,999
.................................... 6
Yes (enter $312.50)
7.
Facilities with gross receipts between $100,000 and $199,999.
.......................... 7
Yes (enter $625)
8.
Facilities with gross receipts between $200,000 and $299,999.
..................... 8
Yes (enter $937.50)
9.
Facilities with gross receipts between $300,000 and $399,999.
....................... 9
Yes (enter $1,250)
10. Facilities with gross receipts of $400,000 or more
...................................... 10
Yes (enter $1,562.50)
11. Total of Section I-B (total of lines 6–10) ........................................................................................... 11
12. Total from Section I-A (line 5 above) .................................................................................................. 12
$
00
13. Total Fee Due (add lines 11 and 12) ................................................................................................. 13
(Continued on back page)
150-609-004 (Rev. 12-02)
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