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" CYCLABLE MATERIALS REPORTING FORM <br /> ,EASE PRINT OR TYPE ALL INFORMATI <br /> (See Instructlons on reverse) <br /> IV. MEETING EXEMPTIONS OR EXCLUSIONS. <br /> A. Was the recycler of the material the same as the generator of the material? Yes d No <br /> I/No then complete items 1 and 2. If Yes then proceed to W.B. <br /> 1. Include documentation that there was a known market for disposition of the recyclable material and any products <br /> manufactured from the recyclable material, AND <br /> ator on or before July 1, 1992, and every two years thereafter. <br /> 2. Provide a completed copy of this form to the gener <br /> B. Indicate the subdivision(s), paragraph(s), and subparagraph(s) (if applicable) of Section 25143.2 that served as the <br /> basis for your claim of exemption or exclusion. Example: 251432(d)(2)(C). <br /> 25143 . 2 (c) ( 2 ) ( a) <br /> V. DESCRIPTION OF THE RECYCLABLE MATERIAL. <br /> A. Provide a general description of the recyclable material that was used in the recycling process. <br /> Paint waste, thinners & solvents <br /> B. Provide a general description of the product(s) that resulted from the recycling process. <br /> clean paint thinner & solvent <br /> C. Identify the constituents and their approximate concentrations which rendered the recyclable material hazardous, and <br /> the final use or the approximate concentrations of those constituents in the final product. <br /> CONSTITUENT NAME APPROXIMATE FINAL USE OR <br /> CONCENTRATION IN APPROXIMATE <br /> RECYCLABLE MATERIAL CONCE PROD OCTN TIN FINAL <br /> see MSDS sheets attached same as new roduc <br /> :A <br /> D. Describe how the recyclable material was beneficially used when recycled in this manner. <br /> reused as paint thinner, wash solvents & cleaning solvents . <br /> VI. CERTIFICATION BY THE OWNER OR OPERATOR OF THE RECYCLING FACILITY. <br /> I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system <br /> designed to assure that qualified personnel property gather and evaluate the information submitted. Based on my inquiry of the <br /> person or persons who manage the system, or those directly responsible for gathering the information, the information is, to the <br /> best of my knowledge and belief, true, accurate and complete. I am aware that there are significant penalties for submitting false <br /> h <br /> information, including the possibility of fines and imprisonment for knowing violations. <br /> L Sup =i Gc)r <br /> Name(P t ype) <br /> Title <br /> Signature Cato Signed <br /> Pages 2 of 2 <br /> Rev:5118192 <br />