Form Pf001 - Solid Waste Annual Permit Fee Quarter Payment printable pdf download

DEPARTMENT OF ENVIRONMENTAL QUALITY

Solid Waste Annual Permit Fee Quarter Payment Form PF001

Return to:

DEQ – Office of Financial Management

P.O. Box 1104, Richmond, Virginia 23218

804/698-4350 or 804/698-4178 (Fax)

Facility Permit Number: __________________________

Date: _________________________________________

Federal Identification Number: ______________________________________ Invoice Number: _________________________________________

Company Name: _____________________________________________________________________________________________________________

Company Address: ________________________________________________________________E-Mail Address: _____________________

Telephone: ______________________________________________________

Fax: __________________________________________

Contact Name: ___________________________________________________

Title: _________________________________________

INSTRUCTIONS: Complete this form and return signed original and copy of the invoice with the first quarter payment by October 1, 2014. A

copy of the form and invoice must also accompany each subsequent payment. Quarter payments are allowed only for those facility operators

that are required to pay annual fees exceeding $8,000 for single or multiple permits.

I agree to pay the original invoice amount, due in four equal payments. Payments are due by the first of the month. I understand the

responsibility to make each quarter payment by the respective due date. If the quarter payment is not made by the deadline, it is further

understood that DEQ may, in addition to other remedies available under the law, issue a notice of failure to pay. The notice shall require

payment of the entire remainder of the annual fee payment within 30 days of the date of the notice, or inform the owner that he shall be

ineligible to opt for the quarter payment schedule until eligibility is reinstated by written notice from the department, or both.

Signed ____________________________________________________________________

Date________________________________

(Certifying Official)

Total Amount Due: $____________________________

Received by DEQ – Office of Financial Management

Due Date

Amount Due

(By Quarter)

(DEQ-OFM Use Only)

October 1, 2014

January 1, 2015

April 1, 2015

June 1, 2015

Revised 7/1/2014

Form Pf001 - Solid Waste Annual Permit Fee Quarter Payment