Hazardous Waste Fee Report Form

A

D

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TOB: HWST

LABAMA

EPARTMENT OF

EVENUE

6/13

B

& L

T

D

USINESS

ICENSE

AX

IVISION

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, S

& L

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S

OBACCO

EVERANCE

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AX

ECTION

P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 353-7827

Hazardous Waste Fee Report

AS AMENDED BY ACT NO. 2013-174

Online filing required at

___________________________________

For the Month of

COMPANY

FEIN

OR

ADDRESS

SSN

CITY

STATE

ZIP

ACCOUNT NUMBER

CONTACT PERSON

TELEPHONE NUMBER

(

)

A

B

C

D

HAZARDOUS WASTE OR

TOTAL TONS RECEIVED

FEE RATE

FEE COLLECTED

HAZARDOUS SUBSTANCE

FOR DISPOSAL

1 Waste listed under Section 3001 of the RCRA of 1976

5 50

1

1

1

as amended and “PCB” waste . . . . . . . . . . . . . . . . . . . . . . . .

5 50

2

2

2

2 All other waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

3

3 TOTAL TONS (Col. B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL FEE (Col. D). . . . .

4

4 Additional fee ($1.00 per ton disposed). (Enter total tons – _____________________________ ) . . . . . . . . . . . . . . . . . . .

5

5 TOTAL FEE (Add fees on lines 3 & 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6

6 Failure to Timely File Penalty (Late filing, greater of 10% of Total Fee or $50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7

7 Failure to Timely Pay Penalty (Late payment, 10% of Total Fee). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

8 Failure to Submit Monthly Report (Penalty not to exceed $250.00) (22-30B-06). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9

9 Failure to Timely Pay Penalty (10% of fee due) (22-30B-05) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

10 Interest (Code of Alabama 1975, Section 40-1-44) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

11 TOTAL AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If payment made through Electronic Funds Transfer (EFT) check this box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

AFFIDAVIT

STATE OF ALABAMA, COUNTY OF ___________________________________________________________________

Before me, the undersigned authority, personally appeared ________________________________________________________________________________ who being by me first duly sworn,

deposes and says that he is a duly authorized representative of _______________________________________________________________________________________________________

and the information herein contained is true and correct.

_________________________________________________________________________

SIGNATURE OF DEPONENT

Sworn to and subscribed before me

this _______________ day of _______________________________________ , _____________ .

_________________________________________________________________________

NOTARY PUBLIC

NOTE: The return and remittance are due no later than the thirtieth (30th) day of the month for the previous calendar month’s activity. A return is

due regardless of activity.