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, CYCLABLE MATERIALS REPORTING <br />PLEASE PRINT OR TYPE ALL INF=ORMATION <br />(See lnstructlons on reverse) <br />IV. MEETING EXEMPTIONS OR EXCLUSIONS. <br />A. Was the recycter of the material the same as the generator of the material? 1] Yes Q No <br />if No then complete items 1 and 2. If Yes then proceed to N.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 />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 subparagraphs) (if applicable) of Section 251432 that served as the <br />basis for your claim of exemption or exclusion. Example: 251432(d)(2)(C). <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 />B. Provide a general description of the product(s) that resulted from the recycling process. <br />C. Identify the constituents and their approximate concentrations which rendered the recyclable material hazardous, and <br />the final use or _ approximate concentrationsproduct. <br />CONSTITUENT NAME APPROXIMATE <br />CONCENTRATION IN <br />RECYCLABLE MATERIAL I <br />FINAL USE OR <br />APPROXIMATE <br />CONCENTRATION IN FINAL <br />PRODUCT <br />D. Describe how the recyclable material was beneficially used when recycled in this manner. <br />Vt. 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 />information, including the possibility of fines and imprisonment for knowing violations. <br />Name (Print or Type) <br />Signature <br />LF e <br />Title <br />71_ Zt—e0 <br />Date Signed <br />Rev. 5/1&92 Page 2 of 2 <br />