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RECYCLABLE MATERIALS REPORTING FORM _ As required by California Health& Safety Code (H&SC) Section 25143.10,which was added by Assembly Bill 1475, introduced by Assemblymember S.Tanner during the 1991 legislative session and published in Chapter 715, this form must be completed by any person who recycles more than 100 kilograms per month of recyclable material under a claim that the material qualifies for exclusion or exemption pursuant to Section 25143.2 of the H&SC. General Instructions For Completing This Form. 1. Complete only one copy of Page 1 for each generator during each reporting period. Complete one copy of Page 2 for each recyclable material from each generator_ Additional copies of the form are available from the local agency. Please do not use photocopies. 2. Report the recycling that has taken place during the prior two calendar years. Once completed, recyclers must submit the form by July 1 of the following year. - then fill out all Sections, and provide a copy of 3. If the generator of the material was not the same entity as the recycler, the completed form to the generator on or before July 1, 1992, and every two years thereafter. 4. When completed, return this form to the local health officer or other authorized local public officer on or before July 1, 1992, and every two years thereafter. The Officers address should be listed in the box on page 1_ 1. Dates of Reporting Period. Beginning and Ending Dates: Enter the beginning and ending dates of this reporting period it. Facility That Recycles The Material. A. Recycling Facility. recyclngU.S. Environmental ection Facility EPA Identification Number: Enter the needslbutf does not yet have anrident'rfication number,hetow er or Agency (EPA) identification number. If the facility operator can contact the Telephone Information Center at (916) 324-1781. Facility Name: Enter the name of the recycling facility. Facility Address: Enter the physical address of the recycling facility. City, County, State, Zip: Enter the city, county, state, and zip in which the recycling facility is located. Contact: Last, First: Enter the name of the on-site contact person. Telephone, FAX: Enter the area code, telephone and FAX numbers (if any) for the recycling facility. B. Owner or Operator of the Recycling Facility. Name: Enter the name of the owner or operator of the recycling facility. Address: Enter the address of the owner or operator of the recycling facility. City, State,Zip: Enter the city, state, and zip of the owner or operator of the recycling facility. Telephone, FAX: Enter the area code, telephone and FAX numbers (if any) for the owner or operator of the recycling facility. III. Generator of The Recyclable Material. A. Generating Facility. Facility EPA Identification Number: Enter the generating facility's 12-character U.S. Environmental Protection Agency(EPA) identification number. If the facility needs but does not yet have an identification number,the owner or operator can contact the Telephone Information Center at(916) 324-1781. Facility Name: Enter the name of the generating facility. Facility Address: Enter the physical address of the generating facility. city, County, State,Zip: Enter the city, county, state, anq zip in which the generating facility is located. Contact: Last, First: Enter the name of the on-site contact person. Telephone, FAX: Enter the area code, telephone and FAX numbers (if any) for the generating facility. B.. Owner or Operator of the Generating. Facility. Name: Enter the name of the owner or operator of the generating facility. Address: Enter the address of the owner or operator of the generating facility. r operator of the generating facility. City, State, ZIp: Enter the city, state, and zip of the owner o Telephone, FAX: Enter the area code, telephone and FAX numbers (if any) for the owner or operator of the generating facility. n' Instructions for Page t