Del. Admin. Code tit. 1, 500, 501, att. C
Name of Person or Entity (the Registrant):
___________________________________________________________________________
Address and Phone Number of the Registrant:
___________________________________________________________________________
___________________________________________________________________________
Address(es) and Phone Number(s) of any and all recycling facilities located in the State of Delaware owned or operated by the Registrant:
___________________________________________________________________________
___________________________________________________________________________
Description of recycling activity engaged in by Registrant:
___________________________________________________________________________
___________________________________________________________________________
Annual Tons Recycled: __________________________________
Annual Tons Disposed of as Residue: _______________________
I hereby represent that I am authorized to file this statement on behalf of the Registrant, and certify that the above information is true and correct to the best of my knowledge, this ___ day of ___________________, A.D. 20___.
____________________________________ ___________________________
Notary Public Signature
Printed Name and Title
Del. Admin. Code tit. 1, 500, 501, att. C