Form CalRecycle328 "Used Oil Re-refined Incentive Payment Claim" - California

What Is Form CalRecycle328?

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, 2017;
  • 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 CalRecycle328 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 CalRecycle328 "Used Oil Re-refined Incentive Payment Claim" - California

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State of California
Department of Resources Recycling & Recovery (CalRecycle)
CalRecycle 328 (New 5/17)
USED OIL RE-REFINED INCENTIVE PAYMENT CLAIM
Instructions for this form can be found on the reverse.
Mail To:
Department of Resources Recycling & Recovery
Print legibly in blue or black ink or type. Indicate N/A
CalRecycle Accounting Office
for any items which are not applicable.
P.O. Box 4025
CLAIMANT INFORMATION
Sacramento, CA 95812-4025
1.
Certification Number:
REPORTING PERIOD
(Select ONLY One)
2.
Name of Payee/Operator:
Jan 1 – Mar 31/Due May 14
Enter Year
DBA:
Apr 1 – Jun 30/Due Aug 14
Payment Address:
3.
}
Jul 1 – Sep 30/Due Nov 14
State:
City:
Zip:
Oct 1 – Dec 31/Due Feb 14
4.
Contact Person :
Telephone Number:
Email Address:
USED OIL
5. Amount of California used lubricating oil received. Include copies of manifests or modified
manifest receipts from used oil hauler and spreadsheet detailing each shipment of oil received
Gallons
from each California entity.
6. Estimated water content of used oil received:
% Water
RE-REFINED OIL PRODUCED
7. Total re-refined oil produced from California used lubricating oil included on line 5 for incentive
payment
Gallons
0.00
8. Total incentive amount claimed (number of gallons from line 7 @ 2¢ per gallon)
$
TOTAL
0.00
9. OUT-OF-STATE FACILITIES
Used Oil was tested prior to processing to meet the standard of used oil as defined in Public Resource Code
(PRC) 48651.5. (a)(2)
Have current agreement with DTSC pursuant to PRC 48662(f)
Have submitted a current re-refinery certification statement (CalRecycle Form 327) per PRC 48662(d)
10. DECLARATIONS AND SIGNATURES
I declare under penalty of perjury under the laws of the State of California that I am authorized to legally bind Claimant and
that to the best of my knowledge and belief the following statements are true and correct: 1) that the information provided in
this claim is complete and correct; and 2) that no other claim has been submitted for the above claimed oil; and 3) that
Claimant has operated in compliance with all Federal, State and local requirements pertaining to the management of this oil;
and 4) the re-refined oil processed from California used lubricating oil meets the standard as defined in California PRC
Section 48620.2(a) (please attach copy of lab tests showing that it meets the ASTM D607-99 standard).
Print, Sign and Return
Date
Signature of Representative of Claimant
Name and Title of Representative (print)
DO NOT WRITE BELOW – FOR STATE USE ONLY
Approved Amount: $
Claim Number:
Claim Reviewer:
Fi$Cal Vendor #:
Date:
Supervisor Approval:
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Print
State of California
Department of Resources Recycling & Recovery (CalRecycle)
CalRecycle 328 (New 5/17)
USED OIL RE-REFINED INCENTIVE PAYMENT CLAIM
Instructions for this form can be found on the reverse.
Mail To:
Department of Resources Recycling & Recovery
Print legibly in blue or black ink or type. Indicate N/A
CalRecycle Accounting Office
for any items which are not applicable.
P.O. Box 4025
CLAIMANT INFORMATION
Sacramento, CA 95812-4025
1.
Certification Number:
REPORTING PERIOD
(Select ONLY One)
2.
Name of Payee/Operator:
Jan 1 – Mar 31/Due May 14
Enter Year
DBA:
Apr 1 – Jun 30/Due Aug 14
Payment Address:
3.
}
Jul 1 – Sep 30/Due Nov 14
State:
City:
Zip:
Oct 1 – Dec 31/Due Feb 14
4.
Contact Person :
Telephone Number:
Email Address:
USED OIL
5. Amount of California used lubricating oil received. Include copies of manifests or modified
manifest receipts from used oil hauler and spreadsheet detailing each shipment of oil received
Gallons
from each California entity.
6. Estimated water content of used oil received:
% Water
RE-REFINED OIL PRODUCED
7. Total re-refined oil produced from California used lubricating oil included on line 5 for incentive
payment
Gallons
0.00
8. Total incentive amount claimed (number of gallons from line 7 @ 2¢ per gallon)
$
TOTAL
0.00
9. OUT-OF-STATE FACILITIES
Used Oil was tested prior to processing to meet the standard of used oil as defined in Public Resource Code
(PRC) 48651.5. (a)(2)
Have current agreement with DTSC pursuant to PRC 48662(f)
Have submitted a current re-refinery certification statement (CalRecycle Form 327) per PRC 48662(d)
10. DECLARATIONS AND SIGNATURES
I declare under penalty of perjury under the laws of the State of California that I am authorized to legally bind Claimant and
that to the best of my knowledge and belief the following statements are true and correct: 1) that the information provided in
this claim is complete and correct; and 2) that no other claim has been submitted for the above claimed oil; and 3) that
Claimant has operated in compliance with all Federal, State and local requirements pertaining to the management of this oil;
and 4) the re-refined oil processed from California used lubricating oil meets the standard as defined in California PRC
Section 48620.2(a) (please attach copy of lab tests showing that it meets the ASTM D607-99 standard).
Print, Sign and Return
Date
Signature of Representative of Claimant
Name and Title of Representative (print)
DO NOT WRITE BELOW – FOR STATE USE ONLY
Approved Amount: $
Claim Number:
Claim Reviewer:
Fi$Cal Vendor #:
Date:
Supervisor Approval:
INSTRUCTIONS FOR COMPLETING USED ONLY RE-REFINED INCENTIVE PAYMENT CLAIM
TO BE ELIGIBLE TO RECEIVE A RECYCLING INCENTIVE PAYMENT FOR REREFINED OIL, YOU MUST REPORT TO
THE DEPARTMENT OF RESOURCES RECYCLING AND RECOVERY (CALRECYCLE) QUARTERLY. USE THIS FORM
TO REPORT HOW MUCH OF THE OIL RECEIVED IS FROM CALIFORNIA, AND WHAT VOLUME OF REREFINED OIL
WAS PRODUCED FROM CALIFORNIA OIL. THE DEADLINE FOR SUBMITTING A QUARTERLY REPORT IS ON OR
BEFORE THE 45TH CALENDAR DAY FOLLOWING THAT QUARTER.
IF ANY INFORMATION IS NOT INCLUDED OR IS INCORRECT ON THE FORM, THE DEPARTMENT OF RESOURCES
RECYCLING AND RECOVERY (CALRECYCLE) MAY ADJUST OR REJECT YOUR REQUEST FOR PAYMENT.
REPORTING PERIOD: Check the box corresponding to the quarter and enter the year of claim reporting period. Each quarter
must be submitted on a separate form. Failure to do so may result in return of the form.
1. Certification Number - Enter the certification number issued by the Department of Resources Recycling & Recovery
(CalRecycle)
2. Name of Payee/Operator/DBA - Enter name as it appears on your Payee Data Record (Std. 204) form on file.
3. Payment Address - Enter the complete address of the location payment should be sent. This address must match the
address on the Payee Data Record form (Std. 204) on file.
4. Contact Person - Enter the name, email address and telephone number of person to contact regarding questions on
the completed claim form.
5. Enter the amount of California used lubricating oil received for the reporting period. Include copies of manifests or
modified manifest receipts from used oil hauler and spreadsheet detailing each shipment of oil received from each
California entity. Claims will be adjusted for incomplete or illegible manifests.
6. Enter the amount of estimated water content in the amount of used oil received.
7. Enter the amount of re-refined oil produced from California used lubricating oil being claimed for incentive payment.
8. Total re-refined incentive amount claimed (Number of gallons from line 7multiplied by 2¢ per gallon).
9. Out-of-State facilities additional certification requirements as listed.
10. A duly authorized representative who has the authority to legally bind claimant must sign this Claim. The signature
must be an original. Rubber stamps or facsimile are not allowed.
ADDITIONAL DOCUMENTATION REQUIRED
Printed copies of manifests or modified manifest receipts from used oil hauler.
Proof that the re-refined oil produced from California Used Lubricating Oil meets the standard as defined in
California PRC Section 48620.2(a).
Spreadsheet detailing each shipment of oil received from each California entity submitted electronically.
DEFINITIONS
“Lubricating Oil” includes, but is not limited to, any oil intended for use in an internal combustion engine crankcase,
transmission, gearbox, or differential in an automobile, bus, truck, vessel, plane, train, heavy equipment, or other machinery
powered by an internal combustion engine defined in PRC 48618.
"Re-Refined Oil" means a lubricant base stock or oil base that has been derived from used oil and meets all of the criteria
defined in PRC, Section 48620.2; specifically that it:
• Is processed using a series of mechanical or chemical methods, or both, including at a minimum, not limited to,
vacuum distillation, followed by solvent reefing or hydro treating, and;
• Is capable of meeting the Physical and Compositional Properties, in addition to the Contaminants and
Toxicological Properties, as defined under the American Society for Testing and Material (ASTM) D6074-99
standard, and;
Is a material that has a performance quality level suitable for use in a finished lubricant?
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