Form CalRecycle196 "Covered Electronic Waste Recycling Payment Claim" - California

What Is Form CalRecycle196?

This is a legal form that was released by the California Department of Resources Recycling and Recovery - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the California Department of Resources Recycling and Recovery;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CalRecycle196 by clicking the link below or browse more documents and templates provided by the California Department of Resources Recycling and Recovery.

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Download Form CalRecycle196 "Covered Electronic Waste Recycling Payment Claim" - California

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Department of Resources Recycling and Recovery
State of California
CalRecycle 196 (Rev. 05/16)
(CalRecycle)
COVERED ELECTRONIC WASTE RECYCLING PAYMENT CLAIM
Please read instructions on the reverse to complete this form. Failure to submit a complete claim package may result in
denial of payment claim. Print legibly in ink or type. Strike through and rewrite any changes, do not use correction fluid or
th
tape. Payment claim is due on or before the 45
day following the end of the reporting month.
I. APPROVED RECYCLER
A. Federal Employer Identification Number (FEIN):
B. Name of Entity:
C. CEW ID #:
D. Payee Mailing Address, City, Zip:
E. Contact Name:
Telephone Number:
Contact E-Mail Address:
F. Reporting Period:
Month
Year
II. PAYMENT CLAIMED FOR CANCELLED COVERED ELECTRONIC WASTES (CEWs)
For CalRecycle Use Only
Fill in applicable lines:
CRTs and/or CRT-containing wastes cancelled
lbs
$
(Attach Worksheet A)
Non-CRT containing wastes cancelled
lbs
$
(Attach Worksheet B)
TOTAL weight and payment claimed
lbs
$
III. REQUIRED SUPPORTING DOCUMENTATION ATTACHED
Check the boxes below to indicate that all required documentation has been attached.
Collection Logs (CalRecycle Form 198)
Cancellation Records/Processing Log
Source Anonymous Logs (CalRecycle Form 198SA)
Bills of Lading
Proof of Designation Documentation (CalRecycle Form 184)
En d-use Destination
Transfer Receipts/Weight Tickets (CalRecycle Form 197)
IV. DECLARATIONS AND SIGNATURES
I hereby declare under penalty of perjury that:
The approved recycler whom I represent is currently in compliance with all Federal, State and local requirements,
including compliance with the requirements of the Act and this Chapter.
All claimed CEWs have been cancelled as specified in Section 18660.32 and are unable to re-enter the payment system,
and all treatment residuals specified in Section 18660.22(c) derived from the claimed CEWs have been shipped to an
end-use destination authorized to receive and further treat those treatment residuals.
I have certified the weights and verified the calculations, including the adjustments for CEWs from non-California sources
and for prior cancellation.
This payment request, including any and all accompanying documents has been examined by me and is true, correct and
complete.
I understand that errors or omissions on my part may result in CalRecycle delaying or denying payment.
I further understand that fraud could result in revocation of the recycler’s approval.
Signature of Authorized Agent
Print or Type Name of Authorized Agent
Title
Prepared and executed this
of
at
,
(day)
(month)
(city)
(state)
FOR CalRecycle USE ONLY
CalRecycle Claim Number
Recycler Approval Active
Date Postmarked
Program Approval
Accounting Approval
Program Approval
Schedule Number
Approved Amount
Page 1 of 2
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Department of Resources Recycling and Recovery
State of California
CalRecycle 196 (Rev. 05/16)
(CalRecycle)
COVERED ELECTRONIC WASTE RECYCLING PAYMENT CLAIM
Please read instructions on the reverse to complete this form. Failure to submit a complete claim package may result in
denial of payment claim. Print legibly in ink or type. Strike through and rewrite any changes, do not use correction fluid or
th
tape. Payment claim is due on or before the 45
day following the end of the reporting month.
I. APPROVED RECYCLER
A. Federal Employer Identification Number (FEIN):
B. Name of Entity:
C. CEW ID #:
D. Payee Mailing Address, City, Zip:
E. Contact Name:
Telephone Number:
Contact E-Mail Address:
F. Reporting Period:
Month
Year
II. PAYMENT CLAIMED FOR CANCELLED COVERED ELECTRONIC WASTES (CEWs)
For CalRecycle Use Only
Fill in applicable lines:
CRTs and/or CRT-containing wastes cancelled
lbs
$
(Attach Worksheet A)
Non-CRT containing wastes cancelled
lbs
$
(Attach Worksheet B)
TOTAL weight and payment claimed
lbs
$
III. REQUIRED SUPPORTING DOCUMENTATION ATTACHED
Check the boxes below to indicate that all required documentation has been attached.
Collection Logs (CalRecycle Form 198)
Cancellation Records/Processing Log
Source Anonymous Logs (CalRecycle Form 198SA)
Bills of Lading
Proof of Designation Documentation (CalRecycle Form 184)
En d-use Destination
Transfer Receipts/Weight Tickets (CalRecycle Form 197)
IV. DECLARATIONS AND SIGNATURES
I hereby declare under penalty of perjury that:
The approved recycler whom I represent is currently in compliance with all Federal, State and local requirements,
including compliance with the requirements of the Act and this Chapter.
All claimed CEWs have been cancelled as specified in Section 18660.32 and are unable to re-enter the payment system,
and all treatment residuals specified in Section 18660.22(c) derived from the claimed CEWs have been shipped to an
end-use destination authorized to receive and further treat those treatment residuals.
I have certified the weights and verified the calculations, including the adjustments for CEWs from non-California sources
and for prior cancellation.
This payment request, including any and all accompanying documents has been examined by me and is true, correct and
complete.
I understand that errors or omissions on my part may result in CalRecycle delaying or denying payment.
I further understand that fraud could result in revocation of the recycler’s approval.
Signature of Authorized Agent
Print or Type Name of Authorized Agent
Title
Prepared and executed this
of
at
,
(day)
(month)
(city)
(state)
FOR CalRecycle USE ONLY
CalRecycle Claim Number
Recycler Approval Active
Date Postmarked
Program Approval
Accounting Approval
Program Approval
Schedule Number
Approved Amount
Page 1 of 2
State of California
Department of Resources Recycling and Recovery
CalRecycle 196 (Rev. 05/16)
(CalRecycle)
INSTRUCTIONS AND DIRECTIONS FOR COMPLETING A
COVERED ELECTRONIC WASTE RECYCLING PAYMENT CLAIM
I. APPROVED RECYCLER
A. Federal Employer Identification Number: Enter entity’s Federal Employer (Tax) Identification Number or Social
Security Number. This must be the same number indicated on the Payee Data Record on file with CalRecycle.
B. Name of Entity: Enter name of business and the CEW ID number assigned by CalRecycle.
C. CEW ID#: Enter your approved CalRecycle CEW ID #. You can not make a claim if you are not an approved Recycler.
D. Mailing Address: Enter the address where your payment should be sent. This must be the same address indicated on
the Payee Data Record on file with CalRecycle.
E. Contact Name, Telephone number, and E-mail address: Enter the name, phone number and email address of the
person to be contacted for questions regarding payment claims.
F. Reporting Period: Enter the reporting month and year covered by payment claim.
II. PAYMENT CLAIMED FOR CANCELLED COVERED ELECTRONIC WASTES (CEWs)
Enter on each line the amount that is applicable to determine the total amount of payment.
III. INDICATE ALL REQUIRED SUPPORTING DOCUMENTATION IS ATTACHED
Check boxes to indicate that all required supporting documentation, as describe below, is attached to claim.
Collection Logs: (CalRecycle Form 198, or equivalent) – Includes collection dates, consumer names and addresses,
type/category of consumer, description of collection activities, estimated weights and unit count, list of approved collectors
with CEW ID#, list of unapproved collectors. All claimed CEWs must have source documentation.
Source Anonymous Logs: (CalRecycle Form 198SA, or equivalent) – Includes dates, contacts, incident location, incident type,
estimated weights, and unit count.
Designation Documentation: (Designated by a California local government to provide CEW collection services on their behalf).
Transfer Receipts/Weight Tickets: (CalRecycle Form 197, or equivalent) Includes dates of transfer, Approved Collectors with
CEW ID #, Approved Recycler with CEW ID#, net weight of material transferred, unit count, description of activities,
description of quantity discrepancies, and source declaration signed by Collector or Dual Entity.
Note: Weight Tickets. This can serve as the Transfer Receipt if signed by both parties and meets other requirements.
Cancellation Records/Processing Log: (Page 3 of CalRecycle Form(s) 196A and/or Form 196B, or equivalent).
Bills of Lading: Weights shipped and description of destination(s). Includes name of transport company destination of end
use, shipment dates and weight of cancelled materials, name and address of buyer.
Receipts of Disposition: Includes description of ultimate disposition of residuals and post cancellation receiving receipts.
IV. DECLARATIONS AND SIGNATURES
This payment claim must be signed by the person authorized as indicated on the Application for Approval form CalRecycle 186.
By signing this claim, the authorized person binds the entity and represents that he/she has verified the information presented to
be correct. The signature must be an original. No rubber stamps or facsimiles are allowed.
The deadline for submitting a payment claim is on or before the 45th day following the end of the reporting month.
If any required information is not included on the forms, attachments or equivalent information,CalRecycle may
reject payment claim.
All requirements are outlined in the California Code of Regulations Title 14 18660.22 -
www.CalRecycle.ca.gov/Electronics/
All covered electronic waste recycling payment claims, inquiries and correspondence pertaining to covered electronic waste payments should
be mailed or delivered to:
ACCOUNTING OFFICE - E-Waste Claim Enclosed
CalRecycle
1001 I Street, P.O. Box 4025, MS #19A
Sacramento, CA 95812
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