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V <br />AOL <br />a <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />HAZARDOUS WASTE <br />RECYCLABLE MATERIALS REPORT — PAGE 1 <br />FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br />f <br />Page 0'-;- <br />FACILITY ID# <br />FACILITY <br />EPA ID # 2 <br />9Bz OS -2- �b 3 <br />BUSINESS NAME (Same. FACILITY NAME., DBAl-Doing Business As) 3 <br />D � V s <br />BEfG,INNING DATE 50a ENDING DATE 501 <br />DATES OF REPORTING PERIOD <br />I. TYPE OF RECYCLING ACTIVITIES <br />If yes, please follow instructions. <br />1. Do you recycle more than 100 kg/month of excluded or exempted <br />502 <br />WYES <br />✓ If YES, you are both the generator and recycler. <br />recyclable material at the same location at which the material was <br />❑ NO <br />Complete one Recyclable Materials Report. Do not <br />generated (onsite recycling)? <br />complete Parts II and V. <br />2. Do you recycle more than 100 kg/month of non -manifested, <br />303 <br />✓ If YES, you are an offsite recycler but not the <br />excluded recyclable materials received from an offisite location <br />❑ YES NO <br />generator. Complete a Recyclable Materials Report <br />(offsite recycling)? <br />for each generator that sends you materials. <br />—Businesses that only send recyclable materials to an offsite recyclers are not required to file this report. — <br />II. OFFSITE GENERATOR OF RECYCLABLE MATERIAL <br />Only complete when the generator is different from the recycler. <br />OFFSITE GENERATOR OF RECYCLABLE MATERIAL 504 <br />OFFSITE GENERATOR EPA ID# 505 <br />STREET ADDRESS 506 <br />PHONE 507 <br />CITY Sag <br />STATE 509 <br />ZIP CODE 510 <br />MAILING ADDRESS (IF DIFFERENT) 511 <br />CITY 513 <br />STATE 513 <br />ZIP CODE 514 <br />IH. CERTIFICATION SECTION <br />1 certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure <br />that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those <br />directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and complete. <br />SIGNATURE OF CERTIFIE <br />DATE 515 <br />1 NAME OF DOCUMENT PREPARER 516 <br />NAME OF SIGNER (print) 517 <br />l� ck &'OS <br />TITLE OF SIGNER Sig <br />�ri trcrc, V�Qccn.aa .t✓r <br />UPCF (1/99 revised) <br />179 <br />