Hazardous Waste Fee Report - Alabama Department Of Revenue

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A
D
R
TOB: HWST
LABAMA
EPARTMENT OF
EVENUE
04/06
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
P.O. Box 327555 • Montgomery, AL 36132-7555 • (334) 242-9627
Hazardous Waste Fee Report
REQUIRED BY ACT NOS. 92-658 AND 2006-306
___________________________________
For the Month of
COMPANY
FEIN
ADDRESS
CONTACT PERSON
CITY / STATE / ZIP
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 as
41 60
amended and “PCB” waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
1
1
2 Acute hazardous waste listed in 40 CFR 261.33(e) and
having an EPA hazardous waste number designation
103 60
beginning with letter “P” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
2
2
3 Toxic hazardous waste listed in 40 CFR 261.33(f) and
having an EPA hazardous waste number designation
66 60
beginning with letter “U” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
3
3
4 Emission control dust/sludge from the primary production
11 60
of steel in electric arc furnaces (K061) . . . . . . . . . . . . . . . . . . .
4
4
4
5 Any hazardous waste that is de-characterized and
11 60
rendered nonhazardous. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
5
5
11 60
6 All other waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
6
6
7
7
7 TOTAL TONS (Col. B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL FEE (Col. D) . . . . . .
8 Additional fee ($1.00 per ton disposed). (Enter total tons – _____________________________) . . . . . . . . . . . . . . . . . . . . . . . . . .
8
9 TOTAL FEE (Add fees on lines 7 & 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
10 Failure to Timely File Penalty (Late filing, greater of 10% of Total Fee or $50) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
11 Failure to Timely Pay Penalty (Late payment, 10% of Total Fee). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
12 Interest ( Code of Alabama 1975 , Section 40-1-44) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
13 TOTAL AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
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. Failure to file a “No Activity” report may result in penalty charges not exceeding $250 according to the provisions of
Code of Alabama 1975, Section 22-30B-6.

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