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12/10/2003 14:28 209468343' FIFTH FLOOR PAGE 02 <br /> UNHUD PROGRAM CONSOLIDATED FORM <br /> HAZARDOUS WASTE <br /> RECYCLABLE MATERIALS REPORT - PAGE Y <br /> FOR EXCLUDED OR EXEMPTED MATERIALS ONLY <br /> FACILITY ID# EPA ID if CAD <br /> BUSINESS NAME Is. .247 FAcTNAME arDB <br /> Z7(f as,0Buse <br /> DATES OF REPORTING PERIOD BEG ING ATE 5so END DATE t <br /> L7 <br /> I.TYPE OF RECYCLING ACTIVITIES <br /> If yes,please follow instructions. <br /> 1. Do you recycle more than 100 kglmonth of excluded or exempted "n ✓ If YES,you arc both the generator and recycler. <br /> recyclable material at the same location at which the material was YES ❑ NO Complete one Recyclable Materials Report. Dom <br /> generated(onsite recycling)? complete Pans Il and V. <br /> 2. Do you recycle more than 100 kemonth of non-manifested, 503 ✓ If YES,you are an offsite recyeler but not the <br /> excluded recyclable materials received from an offisite location ❑ YES XNO generator. Complete a Recyclable Materials Report <br /> (ofRite recycling)? for each generator that sends you materials. <br /> —Buainesaes that OnlySend recyclable materials to an offsite reeyclors are not required to file this report.— <br /> II. OFFSITE GENERATOR OF RECYCLABLE MATERIAL <br /> Only complete when the generator is different Rom the recycler. <br /> OFFSITE GENERATOR OF RECYCLABLE MATERIAL 114J OFFSITE GENERATOR EPA lA9 305 <br /> STREET ADDRESS sub PI-(ONE 5v7 <br /> CITY scs STATE NO ZIP CODE 510 <br /> MAILING ADDRESS(1F DIFFERENT) Tit <br /> CITY 11c STATE 51a ZIP CODE sl+ <br /> III. CERTIFICATION SECTION <br /> 1 certify under penalty of taw that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure <br /> That qualified personnel properly gather and evaluate the Information submitted. Saeed on my inquiry of the person or persons who monage the system or those <br /> directly responsible forgathering infonnatf he information is,to The best of my knowledge and belief,true,accurate,and complete. <br /> SIGNATURE OF s1e PARER <br /> JC�P <br /> (� <br /> NAMEOF ( nl) Sts I TITLE OFSIGNER sis <br /> UPCF(1/99 revised) 179 <br />