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					                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          206.90                                                  15a $                      -

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  66.30             16a $                      -

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a $                      -



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due August 15, 2009                                                           DO NOT
     U.S. Postmark this date:               August 17, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          489.86                                                  15a $                      -

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  149.53            16a $                      -

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a $                      -



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due August 15, 2009                                                           DO NOT
     U.S. Postmark this date:               August 17, 2009                     STAPLE FORMS
  danielle                                                                                                                               SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          471.26                                                  15a $                      -

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  145.21            16a $                      -

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a $                      -



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due August 15, 2009                                                           DO NOT
     U.S. Postmark this date:               August 17, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          258.41                                                  15a $                      -

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  82.31             16a $                      -

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a $                      -



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due August 15, 2009                                                           DO NOT
     U.S. Postmark this date:               August 17, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          206.90                                                  15a

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  66.30             16a

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due: August 15, 2009                                                          DO NOT
     U.S. Postmark this date:               August 15, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          489.86                                                  15a

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  149.53            16a

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due: August 15, 2009                                                          DO NOT
     U.S. Postmark this date:               August 15, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          471.26                                                  15a

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  145.21            16a

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due: August 15, 2009                                                          DO NOT
     U.S. Postmark this date:               August 15, 2009                     STAPLE FORMS
                                                                                                                                         SURCHARGE SECTION
                                                                                                                1955 Workman Mill Road, Whittier, CA 90601-1400
                                                                                                         Mailing Address: P.O. Box 4998, Whittier, CA 90607-4998
                                                                                                                 Telephone: (562) 699-7411, FAX: (562) 908-4224
                                                                                                                                                   www.lacsd.org
                                                                                                                                          STEPHEN R. MAGUIN
                                                                                                                            Chief Engineer and General Manager

                                             HOSPITAL WASTEWATER TREATMENT USER CHARGE STATEMENT
                                                       For Fiscal Year July 1, 2008 to June 30, 2009


7. COMPANY NAME:                                                                                FACILITY ID NO.

8. COMPANY MAILING ADDRESS:                                                                     FEDERAL TAX ID NO.

9. ADDRESS OF WASTEWATER DISCHARGE:                                                             DISTRICT NO.

10. PROPERTY IDENTIFICATION:



                           (Map Book No.)     (Page No.)     (Parcel No.)

11. FEDERAL STANDARD INDUSTRIAL
    CLASSIFICATION (SIC) NO(S)


                                                           CALCULATION OF HOSPITAL OCCUPANCY

12. DISCHARGE OUTLETS TO SEWER                                                 NO. 1    NO. 2        NO. 3            NO. 4                      TOTALS
      Sanitation Districts Permit No(s).

13. ACUTE CARE OCCUPANCY (Average daily occupied
     bed census during the fiscal year)                                                                                             13a
                                                                                                                                                       (Total Flow)
14. SKILLED NURSING and/or INTERMEDIATE CARE OCCUPANCY
     (Average daily occupied bed census during the fiscal year)                                                                     14a

                                SUBMIT A COPY OF THE "PATIENT CENSUS STATISTICS" (PAGE 4.1)

                                    CALCULATION OF HOSPITAL WASTEWATER TREATMENT USER CHARGE

15. ACUTE CARE USER CHARGE (Multiply Line 13a by $                          258.41                                                  15a

16. SKILLED NURSING and/or INTERMEDIATE CARE USER CHARGE (Multiply Line 14a by $                                  82.31             16a

17. TOTAL HOSPITAL WASTEWATER TREATMENT USER CHARGE PAYABLE
     (The sum of Lines 15a and 16a)                                                                                                 17a



CERTIFIED CORRECT BY HOSPITAL ADMINISTRATIVE OFFICER
                                                                                                  Please enclose a check in the full amount shown on Line
I hereby certify under the penalty of perjury that his statement and
                                                                                                  17a. Make the check payable to the County Sanitation
supporting data are complete and correct.                                                         Districts of Los Angeles County.

18. SIGNATURE                                                               19. DATE

20. PRINT NAME and POSITION                                                                       Please use the pre-addressed envelope for return.


21. PREPARED BY                                                                                   For more information call the Industrial Waste Section at:
                                                                                                  (562) 699-7411 or (323) 685-5217, ext. 2600.
22. TELEPHONE NO. OF DISCHARGER                                                                   Please pay by August 15, 2009 to avoid penalty and interest
     (Include Area Code)                                                                          penalty charges.




     Due: August 15, 2009                                                          DO NOT
     U.S. Postmark this date:               August 15, 2009                     STAPLE FORMS

				
DOCUMENT INFO
Description: Federal Tax Id Numbers document sample