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r J1`d i i t cr.ty l\! Ci'NS� <br /> I r_AZAR!0J0QTS WASTE <br /> R E C Y(LA RSL IE MArRER f A iLS REPORT L-PAGE ii <br /> FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br /> A a F_-'oma <br /> . ... - Pale_��,.... <br /> FACILITY ID# 1 EPA ID# 2 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> DATES OF REPORTING PERIOD BEGINNING DATE 500 ENDING DATE 501 <br /> I.TYPE OF RECYCLING ACTIVITIES <br /> If yes,please follow instructions. <br /> 1. Do you recycle more than 100 kg/month 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 N YES ❑ NO Complete one Recyclable Materials Report. Do not <br /> generated(onsite recycling)? complete Parts lI 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 ❑ YESIe� NO generator. Complete a Recyclable Materials Report <br /> (offsite recycling)? y� <br /> 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 /> It. 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 sos 1 STATE S09 ZIP CODE sto <br /> MAILING ADDRESS(IF DIFFERENT) 511 <br /> CITY 512 STATE 513 ZIP CODE 514 <br /> III. CERTIFICATION SECTION <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 ersonnel 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 Ie for gathering the information,the information is,to the best of my knowledge and belief,true,accurate,and complete. <br /> SIG ATURE 'F C/ERTI IER J DATE E OF DOCUMENT PREPARER 516 <br /> NME' IGNER(print) y� 517 TITLE OF SIGNER sts <br /> RA �k8® � ® <br /> UPCF(12/99 revised) <br />