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RECYCLABLE MATERIALS REPORTING FORM PLEASE PRINT OR TYPE ALL INFORMATION (see Instructions on reverse) d I AL HEQLTIi IV. MEETING EXEMPTIONS OR EXCLUSIONS. i SERVICE A. Was the recycler of the material the same as the generator of the mats ha1.R '11'PIK 22 619 If No then complete items 1 and 2. It Yes then proceed to IVB. 1. Include documentation that there was a known market for disposition of the recyclable material and any products manufactured from the recyclable material, AND 2. Provide a completed copy of this form to the generator on or before July 1, 1992, and every two years thereafter. B. Indicate the subdivision(s), paragraph(s),and subparagraph(s) (if applicable) of Section 25143.2 that served as the basis for your claim of exemption or exclusion. Example:25143.2(d)(2)(C). 25143.2 (c)(2) on-site recycling of Hazardous Wastewater V. DESCRIPTION OF THE RECYCLABLE MATERIAL, A. Provide a general description of the recyclable material that was used in the recycling process. Mixer rinse water, container rinse water and contaminated storm water run-off. B. Provide a general description of the product(s)that resulted from the recycling process. Water in product formulas and mixer rinse water. C. Identity the constituents and their approximate concentrations which rendered the recyclable material hazardous, and the final use or the approximate concentrations of those constituents in the final product. CONSTITUENT NAME APPROXIMATE FINAL USE OR CONCENTRATION IN APPROXIMATE RECYCLABLE MATERIAL CONCENTRATION IN FINAL PRODUCT M21 pH < 2 p - Base pH >= PH 6-8 D. Describe how the recyclable material was beneficially used when recycled in this manner. Reused in the manufacture of product and for rinse water. VI. CERTIFICATION BY THE OWNER OR OPERATOR OF THE RECYCLING FACILITY. I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed to assure 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 directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. Mark Laehn Vice President and General Manager Name(Print or Type) Title 22 61271)l Signature Date Signed Rev:5/1892 Page 2 or 2