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RECYCLABLE MATERIALS REPORTING -)RM <br />PLEASE PR'.NT OR TYPE ALL INFORMATION <br />(Sae Instructlons on reverse) <br />IV. MEETING EXEMFTIONS OR EXCLUSIONS. <br />A. Was the recycler of the material the same as the generator of the matenal? bQ Yes r--] No <br />If No then complete items 1 and 2. If Yes then proceed to IV-9- <br />1. <br />V.B_1. Include documentation that there was a known, markat for disposition of the recyc!able material and any products <br />manufactured from the recyclable material, AND <br />2. Provide a completed copy of this form to the generator on or before July 1, 1992, and every two years thereafter. <br />B. Indicate the subdivision(s), paragraph(s), and subparagraoh(s) (if applicable) of Section 251432 that served as the <br />basis for your daim of exemption or exclusion. Example: 251432(d)(2)(C). <br />.9, /43. .2 /�) �Ai /q) <br />V. DESCRIPTION OF THE RECYCLABLE MATERIAL <br />A. Provide a general description of the recyclable material that was used in the recfc!ing process. <br />P,.fr, o u i Wh"5 Cr TArtiiv F,n s tf'- sa c v Ts <br />B. Provide a general description of the product(s) that resulted from the recfciing process. <br />C. Identify the constituents and their approximate concentrations which rencered the rec�c!able material hazardous, and <br />the final use or the approximate concentrations of those constituents in the final product. <br />CONSTITUENT NAME <br />APPROX!MATE <br />CONCENTRATION IN <br />RECYCLABLE MATERIAL <br />FINAL USE OR <br />APPROXIMATE <br />CONCENTRATION IN FINAL <br />PROOUCT <br />tM11<0Int <br />I <br />I <br />D. Describe how the recyclable maierial was beneficially used when recycled in this manner. <br />us 4es 6A,,T 7-ff��vi✓fF Y- ff sc� t, ✓ E c�G <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. 1 am aware !hat there are significant penalties for submitting false <br />information, including the possibility of fines and imprisonment for knowing vitiations. <br />f & L $/s ch`c F� 2G /� �CPFE TY !�/•r-%ii/� <br />_ Name (Print or Type) idle <br />gnatur <br />_ /(oC) <br />C)dto Signed <br />Rev: 5/78192 Page 2 of 2 <br />