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a <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />RECYCLABLE MATERIALS REPORT - PAGE 1 <br />FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br />Page � of <br />FACILITY ID# <br />1. <br />EPA [D # 2. <br />BUSINESS NAME (Same u FACILITY NAME or DBA - Doing Business As) 3. <br />DATES OF REPORTING PERIOD <br />BEGINNING DATE 500. <br />ENDING DATE sol_ <br />I. TYPE OF RECYCLING ACTIVITIES <br />If yes, please follow instructions. <br />sot. <br />1, Do you recycle more than 100 kg./month of excluded or <br />exempted recyclable material at the same location at which the ❑ YES ❑ NO <br />4 If YES, you are both the generator and recycler. <br />material was generated (on-site recycling)? <br />one Complete Recyclable Materials Report. Do not <br />p y P <br />complete Parts II and W. <br />503, <br />2, Do you recycle more than 100 kg./month of non -manifested, <br />4 If YES, you are an off-site recycler but not the <br />excluded recyclable materials received from an off-site location ❑ YES ❑ NO <br />generator. Complete a Recyclable Materials Report <br />(off-site recycling)? <br />for each generator that sends you materials. <br />--Businesses that only send recyclable materials to off-site recyclers are not required to file this report -- <br />II, OFF-SITE GENERATOR OF RECYCLABLE MATERIAL <br />Complete only when the generator is different from the recycler. <br />OFF-SITE GENERATOR OF RECYCLABLE MATERIAL 504, <br />OFF-SITE GENERATOR EPA ID# 505. <br />STREET ADDRESS 506. <br />PHONE 50T <br />CITY 508 <br />STATE 509. <br />ZIP CODE S10 <br />MAILING ADDRESS (IF DIFFERENT) 511 <br />CITY 512. <br />STATE 513, <br />ZIP CODE 514 <br />III. CERTIFICATION SECTION <br />I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in <br />accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. <br />Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, <br />the information is, to the best of my knowledge and belief, true, accurate, and complete. <br />SIGNATURE OF CERTIFIER <br />DATE 515. <br />NAME OF DOCUMENT PREPARER 516 <br />NAME OF SIGNER (print) 517. <br />TITLE OF SIGNER 518. <br />UPCF (1199) Hwfrecyc 1/4 www.unidocs.org Rev. 02/16100 <br />