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_ LIED PROGRAM CONSOLIDATED FOS <br /> HAZARDOUS WASTE <br /> RECYCLABLE MATERIALS REPORT- PAGE 1 <br /> FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br /> I PPM <br /> tit Li Page_of <br /> FACILITY ID# i. EPA ID# 2, <br /> C_AD005415633 JUN 2 8 201 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3, <br /> 14 r+&Th N <br /> DATES OF REPORTING PERIOD BEGINNING DATE 5001 1 <br /> F110? 'i�CES Sat. <br /> 01 Jan 2010 31 Dec 2411 <br /> I.TYPE OF RECYCLING ACTIVITIES <br /> If yes,please follow instructions. <br /> 502, <br /> 1. Do you recycle more than 100 kg./month of excluded or 4 If YES, you are both the generator and recycler. <br /> exempted recyclable material at the same location at which the ® YES ❑ NO <br /> material was generated(on-site recycling)? Complete one Recyclable Materials Report. Do not <br /> complete Parts II and W. <br /> 503, <br /> 2. Do you recycle more than 100 kg./month of non-manifested, 4 If YES, you are an off-site recycler but not the <br /> excluded recyclable materials received from an off-site location ❑ YES ® NO generator. Complete a Recyclable Materials Report <br /> (off-site recycling)? 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. OFF-SITE GENERATOR EPA ID# 505 <br /> STREET ADDRESS 506. PHONE 507, <br /> CITY 508. STATE 509. ZIP CODE 510. <br /> MAILING ADDRESS(IF DIFFERENT) 511. <br /> CITY 512. STATE 513. 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 /> SIGNAT IFIER DATE 515. 1 NAME OF DOCUMENT PREPARER 516, <br /> 6-27-12 <br /> NAME OF SIGNER(print) 517. TITLE OF SIGNER 518. <br /> Ben Cuthbertson Environmental Health& Safety Manager <br /> UPCF(1199)Hwfreeyc 1/4 www.unidoes.org Rev,02/16/00 <br />