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t RECYCLABLE MATERIALS REPORTING FORM PLEASE PRINT OR TYPE ALL INFORMATION ^i`' :fI p ^ (See Instructions on reverse) IV. MEETING EXEMPTIONS OR EXCLUSIONS. A. Was the recycler of the material the same as the generator of the material? (5 Yes O No If No then complete items 1 and 2. If Yes then proceed to W.B. 1. Include documentation that there was a known market for disposition of the recyclable material and any products manufactured from the recyclable material, AND 2. Provide a completed copy of this form to the generator on or before July 1, 1992, and every two years thereafter. B. Indicate the subdivision(s), paragraph(s), and subparagraph(s) (if applicable) of Section 25143.2 that served as the basis for your claim of exemption or exclusion. Example: 25143.2(d)(2)(C). 25143.2 (d)(1) and 25143.2 (c)(2) V. DESCRIPTION OF THE RECYCLABLE MATERIAL. A. Provide a general description of the recyclable material that was used in the recycling process. The material is a coolant that is used in several of the grinding machines. B. Provide a general description of the product(s) that resulted from the recycling process. Two products result from the recycling process. (1) the coolant and (2) grinding waste which is manifested and hauled off -sit as a hazardous waste. C. Identify the constituents and their approximate concentrations which rendered the recyclable material hazardous, and the final use or the approximate concentrations of those constituents in the final product. CONSTITUENT NAME J APPROXIMATE CONCENTRATION IN RECYCLABLE MATERIAL FINAL USE OR APPROXIMATE CONCENTRATION IN FINAL PRODUCT Ethanolamine Diethanolamine % Triethanolamin % % Mineral Oil Barium Compounds 3% 3% 0. Describe how the recyclable material was beneficially used when recycled in this manner. The recycled coolant is re -used in the grinding machines. VI. CERTIFICATION BY THE OWNER OR OPERATOR OF THE RECYCLING FACILITY. I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel property gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those directly responsible for gathering the information, the information is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing vioiations. Peter leton Name (Print or T ypej Human Resources Manager Title -- -7 /Z 8 0 Signed Rev: 5/1&92 Page 2 of 2