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RECYCLABLE MATERIALS REPORTING FORM <br />PLEASE PRINT OR TYPE ALL INFORMATION <br />(Sae Instructions on revorso) <br />IV. MEETING EXEMPTIONS OR EXCLUSIONS. <br />A. Was the recycler of the material tho same as the generator of the material? M Yes Q No <br />11 No then complete items f and 2. N Yes Ilion procoed to IV.S. <br />1. Include documentation that thore was a known market for disposition of tho recyclabla material and any products <br />manufactured from the recyclable niatorial, 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 subparagraph(s) (if applicable) of Stiction 25143.2 that served as the <br />basis for your claim of exemption or exclusion. Example: 25143.2(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 <br />_ <br />APPROXIMATE <br />CONCENTRATION IN <br />RECYCLABLE MATERIAL <br />FINAL USE OR <br />APPROXIMATE <br />CONCENTRATION IN FINAL <br />PRODUCT <br />see MSDS sheets attached <br />same as new product <br />D. Describe how the recyclable material was beneficially used when recycled in this manner. <br />reused as paint thinner, wash solvents & cleaninq 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 his <br />properly 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 aro significant penalties for submitting false <br />information, including the possibility of fines and imprisonmont for knowing violations. <br />Supprvisor <br />Title <br />Date Signed <br />Rov: 511"2 Page 2 of 2 <br />