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UNIFIED PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> RECYCLABLE MATERIALS REPORT - PAGE 1 <br /> FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br /> P. of <br /> FACILITY ID# TT—JEPA ID 11 2 <br /> CA?,660 z6;L lam_. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> 1PRemmay, FaVLSWA14 <br /> BEGINNING DATE 500 ENDING DATE 501 <br /> DATES OF REPORTING PERIOD ! ( –t <br /> I.TYPE OF RECYCLING ACTIVITIES <br /> If yes,please follow instructions. <br /> 1. Do you recycle more than 100 kgtmonth of excluded or exempted 502 4 If YES,you are both the generator and recycler. <br /> recyclable material at the same location at which the material was YES ❑ NO Complete one Recyclable Materials Report. Do not <br /> generated(onsite recycling)? complete Parts II and V. <br /> 2. Do you recycle more than 100 kg/month of non-manifested, 503 4 If YES,you are an offsite recycler but not the <br /> excluded recyclable materials received from an offisite location ❑ YES ERNO generator. Complete a Recyclable Materials Report <br /> (offsite recycling)? for each generator that sends you materials. <br /> --Businesses that only send recyclable materials to an offsite recyclers are not required to file this report.-- <br /> f <br /> II. OFFSITE GENERATOR OF RECYCLABLE MATERIAL <br /> Only complete when the generator is different from the recycler. <br /> OFFSITE GENERATOR OF RECYCLABLE MATERIAL 504 OFFSITE GENERATOR EPA ID# 505 <br />` STREET ADDRESS 506 PHONE 507 <br /> CITY s0s STATE 509 ZIP CODE no <br /> MAILING ADDRESS(IF DIFFERENT) SII <br /> CITY 512 STATE 513 ZIP CODE 514 <br /> f <br /> I III. CERTIFICATION SECTION <br /> l' <br /> I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure <br /> that qualified rsonneI properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system,or those <br /> directly re onsi to for gathering the information,the information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> SIG ATURE CER IER - DATE sls NAME OF DOCUMENT PREPARER 516 <br /> eL 5 (CIE YaWti4 <br /> N ME GNER <br /> (print) 517 TITLE OF SIGNER S1B <br /> —. <br /> C WA�-�'E[�s _. <br />�: UPCF(12/99 revised) <br />