Statement Of Earnings - Sc Public Service Commission

Statement Of Earnings - Sc Public Service Commission - 2003

SOUTH CAROLINA PUBLIC SERVICE COMMISSION

GROSS RECEIPTS FOR THE TWELVE (12) MONTHS ENDING DECEMBER 31, 2003

HAZARDOUS WASTE FOR DISPOSAL CARRIERS

______________________________________________________________________________

Company Name

FEIN

______________________________________________________________________________

Address

Telephone #

______________________________________________________________________________

City

Officers of Company:

President _____________________________________________

Secretary _____________________________________________

Treasurer _____________________________________________

STATEMENT OF EARNINGS

Total Intrastate Regulated Receipts in South Carolina for the Twelve (12)

Months Ending December 31, 2003 $ ______________________

Certificate Number: ____________________________

State of ___________________________________________________________

County of _________________________________________________________

Personally appeared before me _______________________________________

Who, being duly sworn, says that he/she is the __________________________

Of the __________________________ Company and that the foregoing

statement for the year ending December 31, 2003 is correctly taken from the

books and records of said Company, and is true to the best of his/her

knowledge and belief.

Sworn to before me this ___________ day of ___________ , 20____.

________________________________

_____________________

________________________________ (L.S.)

Notary Public

Return via E-mail to:

Harold.Callaway@psc.state.sc.us

Return via US mail to:

Public Service Commission of South Carolina

Audit Department-Attn. Harold Callaway

P.O. Drawer 11649

Columbia, SC 29211

Return Deadline August 31, 2004

Statement Of Earnings - Sc Public Service Commission - 2003