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Form BOE-501-LA Fillable Occupational Lead Poisoning Prevention Fee Return
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(1) Lead present in materials which are altered or disturbed and have a lead concentration less than (0 5) percent (5000 ppm) by weight; (1) Lead that was not altered or disturbed during the operation of the employer's business and was present in a form or contained in such a (10 PENALTY [multiply line 9 by 10% (0 10) if payment is made after the due date shown above] $) (11 INTEREST $) (11 INTEREST: One month's interest is due on the total fee for each month or fraction of a month that payment is made after the due date The adjusted monthly interest rate is ) (12 TOTAL AMOUNT DUE AND PAYABLE (add lines 9 10 and 11) $) (2 Use this box to enter the total number of your employees at all California locations (see Definitions in the Instructions on the back of this return) ) (2) Lead present in materials where the total weight of such materials altered or disturbed during the calendar year is known to be 16 ounces (2) Lead that was present as a result of general environmental contamination which was not the result of the employer's business (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN 9 Enter the total fee due (amount from line 2 3 or 4 for Category A or line 6 7 or 8 for Category B) $) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category A: (Complete only if you are in Category A) 1 Less than 10 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE $) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category A: (Complete only if you are in Category A) 2 10 to 99 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category A: (Complete only if you are in Category A) 3 100 to 499 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category A: (Complete only if you are in Category A) 4 500 or more employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category B: (Complete only if you are in Category B) 5 Less than 10 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE $) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category B: (Complete only if you are in Category B) 6 10 to 99 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category B: (Complete only if you are in Category B) 8 500 or more employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (A NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN Category B: (Complete only if you are in Category B): 7 100 to 499 employees B AMOUNT OF FEE C AMOUNT OF FEE DUE ) (B O E USE ONLY) (CLEAR) CLEAR (DATE) (DUE ON OR BEFORE) (EMAIL ADDRESS) (one pound) or less by weight; or (PRINT NAME AND TITLE) (PRINT) PRINT (TELEPHONE (AREA CODE)) (TELEPHONE) (text) (text) (YOUR ACCOUNT NO ) [ FOID ] 1 Less than 10 employees (if less than 10 employees check box at right) 1 $ $ 10 Penalty [multiply line 9 by 10% (0 10) if payment is made after the due date shown above] PENALTY 10 $ 2 10 to 99 employees 2 3 100 to 499 employees 3 5 Less than 10 employees (if less than 10 employees check box at right) 5 $ $ 500 or more employees 4 4 6 6 10 to 99 employees 7 7 100 to 499 employees 8 500 or more employees 8 94279 0088 You may also visit the BOE website at www boe ca gov or call the Taxpayer Information Section at 1 800 400 7115 (TTY:711); address above All employers in industries for which there is evidence of a potential for lead poisoning are required to file the Occupational Lead Always write your account number on your check or money order Make a copy of this document for your records AMOUNT OF application to the CDPH within 180 days from the due date of this return at any California site of my business operation during the calendar year I understand that if I do not complete a waiver application be mailed to you by CDPH only if you checked Box 1B for a paper application If you checked Box 1A instructions will be mailed to you for BEFORE PREPARING BOARD OF EQUALIZATION BOE 501 LA (BACK) REV 19 (4 13) BOE 501 LA (FRONT) REV 19 (4 13)STATE OF CALIFORNIA BOE USE ONLY California Code of Regulations title 17 section 38005 and you have not completed Section I you are required to complete Section II and pay the fee California only) 1 866 627 1587 or (out of state) 1 510 620 5740 or write to: California Department of Public Health OLPPP Attention: Fee Waiver call 1 855 292 8931 Mandatory EFT accounts' must pay by EFT or ePay Be sure to sign and mail your return by the due date can request a fee waiver If you will be requesting a waiver you should complete Section I and follow the instructions A fee waiver application will Category A: (Complete only if you are in Category A) Category B: (Complete only if you are in Category B) Complete this section if you are not requesting a fee waiver The fee category (A or B) that is applicable to your business is shown above Complete this section if you are requesting a fee waiver Please note: You are required to check box 1 and box 1A or 1B and enter the day during the calendar year that is if no employee works on more than one day during the calendar year in any location where De minimus amount means any of the following: DEFINITIONS (according to section 38001 of title 17 of the California Code of Regulations) (CCR) do not need to complete Section II DUE ON OR BEFORE due This section shows the rates for both Category A and Category B reporting The appropriate category for your business is shown on the front of Each year CDPH provides the Board of Equalization (BOE) with a list of industries that have the potential for occupational lead poisoning The EMAIL ADDRESS Employee160 hours means any individual employed for at least in the prior calendar year (during the reporting period shown on the front of this employers who do not have lead or lead containing materials present or who only have a de minimus (minimal) amount present at any California site Enter the total fee due (amount from line 2 3 or 4 for Category A or line 6 7 or 8 for Category B)9 9 $ examined by me and is to the best of my knowledge and belief a true correct and complete return FEE DUE FOR CATEGORY "A" OR "B" REPORTING forth by the U S Office of Management and Budget in the Standard Industrial Classification Manual 1987 from the main menu select the option Special Taxes and Fees GENERAL INFORMATION Health (CDPH) as being in one of these industries HOW TO FILE I hereby certify that this return including any accompanying schedules and statements has been I will request a fee waiver because lead or lead containing materials were not present or were present in de minimus (minimal) amounts If you checked the box to request a fee waiver do the following: If you have specific questions regarding fee waivers contact the CDPH Occupational Lead Poisoning Prevention Program by calling toll free (in If you need additional information please contact the State Board of Equalization Special Taxes and Fees P O Box 942879 Sacramento CA including job sites or in the materials and processes used in the operation of the employer's business with the following exceptions: industries are designated by Standard Industrial Classification (SIC) codes CDPH also provides the BOE with a list of employers whose business INTEREST 11 $ INTEREST: One month's interest is due on the total fee for each month or fraction of a month that payment is made after the due date The adjusted monthly interest rate is lead containing materials are being altered or disturbed then the amount is de minimus lead containing materials present in any amount or who only have a de minimus (minimal) amount in their business operations may request a Lead present in materials where no such material is altered or disturbed at any individual employee's place of employment on more than one Lead was not present at the place of employment means that no amount of lead or lead containing material was present at the place of employment mail to the Board of Equalization Fee returns and payments that are mailed must be postmarked on or before the due date shown on the return If Make check or money order payable to State Board of Equalization manner that it could not be inhaled or ingested (examples are undisturbed building materials unused materials and supplies intact lead not constitute a fee waiver NUMBER OF EMPLOYEES DURING CALENDAR YEAR COVERED BY THIS RETURN number of employees in box 2 A fee waiver application and instructions will be sent to you by the CDPH after this return is received and OCCUPATIONAL LEAD POISONING PREVENTION FEE RETURN OCCUPATIONAL LEAD POISONING PREVENTION FEE RETURN INSTRUCTIONS of a potential for occupational lead poisoning to pay the Occupational Lead Poisoning Prevention Fee Those employers who do not have lead or operations fall within the listed industries or a waiver is not granted the fee is due The BOE will bill you for any fee due plus interest at the statutory rate Employers completing this section Payments: You can make your payment by paper check Online ACH Debit (ePay) or by credit card To use ePay go to our period for which the fee is due along with a remittance payable to the State Board of Equalization Under R&TC; section 55042 in the Fee Collection Persons completing this section may file the return without payment However if a waiver request and documentation are not submitted as required PO BOX 942879 Poisoning Prevention Fee Return This return is being sent to you because you were identified by the California Department of Public PREPARATION OF RETURN Prevention Program in the California Department of Public Health (CDPH) Procedures Law late payments result in a 10 percent (0 10) penalty and interest at an adjusted annual rate established under R&TC; section 6591 5 processed by the Board of Equalization (BOE) The BOE does not mail or approve fee waiver applications Indicate any corrections to your RA B/A AUD REG READ INSTRUCTIONS Read Sections I and II of the return and complete the section that is applicable to you Complete the bottom line of the return sign and date and Request 850 Marina Bay Parkway Bldg P 3rd Floor Richmond CA 94804 or visit the CDPH website at www cdph ca gov/programs/olppp return for your records Please include the account number shown at the top of your return on all correspondence Please be certain to include return) regardless of whether the individual's specific job involved potential exposure to lead or lead containing materials Review the following information to determine which section on the front of the return you are required to complete RR QS FILE REF SACRAMENTO CA 94279 6029 Section 105190 of the California Health and Safety Code requires all employers with 10 or more employees in an industry for which there is evidence SECTION I SECTION I of this return is provided for employers to inform the BOE that no fee is required at this time because a fee waiver will be requested Only SECTION II SECTION II of this return is provided for employers to report and pay fees due If you have a business operation described by an SIC code listed in Select type of application: A Send a paper application Send instructions for applying electronically via the Internet or B Sign and date this return and send it to the address above Maintain a copy for your records The filing of this return is required and does SIGNATURE PRINT NAME AND TITLE SPECIAL TAXES AND FEES Standard Industrial Classification (SIC) code means a system of four digit numerical codes to designate the activities of a business operation set storage batteries); or submitting your waiver request via the Internet Employers that wish to request a fee waiver must send their completed paper or electronic TELEPHONE temporary fee waiver which if granted will relieve them of paying a fee for the calendar year Waivers must be renewed each year An employer the back of this return) the due date falls on a Saturday Sunday or legal holiday returns postmarked on the next business day are considered timely Retain a copy of the the return with your SIC code If you have any questions about how to complete Section II please contact us at the number listed below TOTAL AMOUNT DUE AND PAYABLE (add lines 9 10 and 11) 12 12 $ Under Revenue and Taxation Code (R&TC;) section 43152 13 every employer subject to the fee is required to file an annual return following the Use this box to enter the total number of your employees at all California locations (see Definitions in the Instructions on website at www boe ca gov click on the eServices tab and log in to make a payment To pay by credit card go to our website or with 10 or more employees that is not granted a waiver is subject to the fee These fees are used to fund the Occupational Lead Poisoning with your SIC code within 180 days following the due date of this return or if a waiver is not granted the fee plus applicable interest is due YOUR ACCOUNT NO your email address at the bottom of the return