HHW CESQG Materials Reporting Indiana HHW Grant Program {51989}

Office of Pollution Prevention and Technical Assistance HHW GRANT PROGRAM 402 West Washington Street, W041 State Form 51989 (11-04) P.O. Box 7095 Indiana Department of Environmental Management Indianapolis, IN 46207-7095 Internet: http://www.in.gov/idem/resources/ grants_loans/recycling/ INSTRUCTIONS: Report on all materials you collected, even if some materials were not grant funded. Methods may include reuse, recycling, treatment, incineration, or disposal. HHW/CESQG Materials Reporting Indiana HHW Grant Program SECTION 1 Date: Reporting Period (enter dates) Grantee: Person Completing Report: SECTION 2 Material Number of HHW Customers Number of Reuse Customers Number of CESQG Customers Reuse Materials Latex paint Oil base paint Aerosols Pesticides-solid Pesticides-liquid Flammable liquids Lab pack Propane tanks - 1 lb. Propane tanks - 20 lb. Photographic fixer Freon tanks Fire extinguishers Electronics Lead acid batteries (Auto) Alkaline batteries Hazardous properties batteries Syringes Pharmaceuticals Ballasts Capacitors Other GRANT INFORMATION Action Review Number (ARN): FROM: TO: HHW/CESQG MATERIALS COLLECTION DATA Totals of Materials Processed Average Price Method of Disposal During Grant Term Per Unit or Recycling Number or Pounds Name of Contractor American LegalNet, Inc. www.FormsWorkflow.com