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10/13/2011 18:00 2098322 BARBOSA MAINTENANCE PAGE 01/02 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> RECYCLABLE MATERIALS REPORT-PAGE 1. HAZARDOUS WASTE <br /> FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br /> FACILITY IDA <br /> � EPA ID N Page_ of <br /> CARoo o16y 1.3 2 a <br /> BUSINESSNAME(sameu PACTU NAWorDBA-D1nggadners Ar) <br /> S'lx aosq c.g3rn6iS 1,1 C. <br /> DATES OF REPORTING PERIO BEGINNING DAENDING DATE Col <br /> I.TYPE OF RECYCLING ACTIVITIES <br /> If yes,please follow instructions. <br /> 1. Do you recycle mor:than 100 grmomh of"eluded or exempted wz ✓ If YES,you are both die generator and recyeler, <br /> mcyclahla mtnrial at un,same oeallon at which the material was ES ❑ NO Complete one R <br /> generated(onsite mcycling)7 P Recyclable Materials Report. Do not <br /> complete Parts 11 and V- <br /> 2. Do you recycle more than 100 /month ofnen-manifested, tar d If YES,you arc an oftkite recycicr but nnr be <br /> excluded recyclable"rate,Iola r roived Dom an otfitite location <br /> (offsilerccycling)? YES �NO generator- Complete a Recyclable Materials Report <br /> for each generator that sends you materials. <br /> —Boa; .,w.s that only send recyclable materials to an ot191te re:yelera are not required to file this report.- <br /> II. OFFSITE GENERATOR OF RECYCLABLE MATERIAL <br /> Only complete when the generator is different from the recyelcr. <br /> OFFSITE GENERATOR OI•' I ARI.B MATERIAL sM OPFSI1'P OENIatATOR FPA IDA sui <br /> STREET ADDRESS <br /> sos PHONE. am <br /> CITY fas STATE rm ZIP CODE Sla <br /> MAILING ADDRESS(IF DIFFERENT) <br /> sl I <br /> OITY "� STATE sia ZIP CODE sla <br /> III. CERTIFICATION SECTION <br /> 1 certify under penally of law that th s document and all attaehmema were prepared Under my direction m supervision in accordance with a system designed to assure <br /> that qualified personnel properly gat larand evaluate the information submitted. Based on my inquiry of the person or persons who manage thc systems or those <br /> directly responsible for gathering th information,die information is,to the best of my knowledge and belief,true,accurate,and comptete. <br /> SIGNATURE OP�CERTTFIER DATE srs NAME OP DOCUMENT PREPARER sla <br /> NAME O/ F$IGN�ER(print) sl7 �y 1 K a4,t 43 o nq <br /> rrriz OF sIGNER sis <br /> /VIA <br /> UPCF1/� <br /> ( 9 revised) 16 <br />