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REC'. _ABLE MATERIALS REPORTING IM IV. MEETING EXEMPTIONS OR EXCLUSIONS. A. If the recycler of the material was the same as the generator of the material, then answer Yes to the question\for answer No, then you are required to complete steps one and two listed here on the form. B. Basis for exemption or exclusion. In this section, indicate the part(s) of Section 25143.2 that pertains to you exemption or exclusion. V . DESCRIPTION OF THE RECYCLABLE MATERIAL. A. In the spaces provided, provide a general description of the recyclable material that was used in the recycling process. For example, 'Spent Petroleum-Based Solvent." B. In the spaces provided,describe the product(s) that resulted from the recycling process. C. Use this table to list the constituents of the recyclable material that would have rendered the material hazardous if it was a waste. Also list the same for the product. 1. Constituent Name: List each constituent of the recyclable material that met or exceeded the level allowed in the California Code of Regulations, Chapter 11. 2. Approximate Concentration in Recyclable Material: List the approximate concentration (and units of measure) for each constituent that met or exceeded the level allowed in the California Code of Regulations, Chapter 11. 3. Final Use OR Approximate Concentration in Final Product: State the final use of the recyclable material, or if the material was used to make a product, then list the approximate concentration of each listed constituent (and unit of measure). D. In the spaces provided, describe how the recyclable material was beneficially used when recycled in this manner. V1. CERTIFICATION BY THE OWNER OR OPERATOR OF THE RECYCLING FACILITY. This section must be completed by the owner or operator of the recycling facility. WHEN COMPLETED, SUBMIT THIS FORM TO YOUR LOCAL ENVIRONMENTAL HEALTH AGENCY. DO NOT SEND THIS FORM TO DTSC. GENERAL INFORMATION Who Must Complete This Form? 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 California Health & Safety Code (H&SC). What Recyclable Materials Are Exempt From Reporting Requirements? The following materials are exempt from completion of this form: • Recyclable materials generated in a product or raw material storage tank, • Product or raw material transport vehicles and vessels, • Product or raw material pipelines, Materials in a manufacturing process unit, or an associated nonwaste treatment manufacturing unit. However, the above materials do become subject to reporting requirements when the recyclable material exits the unit in which it was generated, unless: • the unit is a surface impoundment, or • the material remains in the unit for more than 90 days after the unit ceases to be operated for manufacturing, storage, or transportation of the product or raw material. When Must I Complete This Form? This form must be completed and submitted to the local Health officer or other authorized total public officer on or before July 1, 1992, and every two years thereafter. What Are The Penalties For Not Completing This Form? Upon conviction, the violator would be guilty of a misdemeanor and would face a fine of not more than one thousand dollars, or imprisonment for up to six months in the county jail, or both fine and imprisonment. Repeat offenders face up to a year in the county jail, or up to two years in state prison, plus a fine ranging from $5,000 to$25,000 (H&SC, Article 8, §25190). Instructions for Page 2