Form Hc-500 - Hazardous Chemical Inventory Fee Return Page 2
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1
2FACILITY INFORMATION
HC-500 SCHEDULE B
Facility Name _________________________________________________________
Facility Address or Location ______________________________________________
City______________________________
State _____
Zip Code ____________
Phone Number
(
) _________________________
County ___________________________
Title III ID# (issued by IDEM)
Category Code (Check
)
A(
)
B(
)
C(
)
E(
)
1 box only
$200.00
$100.00
$50.00
$0.00
New Facility
Existing Facility Omitted from Schedule A
Facility Name _________________________________________________________
Facility Address or Location ______________________________________________
City______________________________
State _____
Zip Code ____________
Phone Number
(
) _________________________
County ___________________________
Title III ID# (issued by IDEM)
Category Code (Check
)
A(
)
B(
)
C(
)
E(
)
1 box only
$200.00
$100.00
$50.00
$0.00
New Facility
Existing Facility Omitted from Schedule A
Facility Name _________________________________________________________
Facility Address or Location ______________________________________________
City______________________________
State _____
Zip Code ____________
Phone Number
(
) _________________________
County ___________________________
Title III ID# (issued by IDEM)
Category Code (Check
)
A(
)
B(
)
C(
)
E(
)
1 box only
$200.00
$100.00
$50.00
$0.00
New Facility
Existing Facility Omitted from Schedule A
Facility Name _________________________________________________________
Facility Address or Location ______________________________________________
City______________________________
State _____
Zip Code ____________
Phone Number
(
) _________________________
County ___________________________
Title III ID# (issued by IDEM)
Category Code (Check
)
A(
)
B(
)
C(
)
E(
)
1 box only
$200.00
$100.00
$50.00
$0.00
New Facility
Existing Facility Omitted from Schedule A
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Parent category: Financial