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This form must be completed and signed by the responsible party and submitted no later than 30 days after the end of each quarter.

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* 1. Contact Information

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* 2. Reporting Quarter

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* 3. Total number of recyclable paper carryout bags provided:

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* 4. Total number of recyclable paper carryout bags ordered:

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* 5. Total number of reusable bags provided:

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* 6. Total amount of monies collected for recyclable carryout and reusable bags:

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* 7. Total number of carryout bags provided free of charge per the exemptions in 8.52.060:

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* 8. Summary of any efforts taken to promote the use of reusable bags:

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* 9. By entering your name and date below, you declare under penalty of perjury that everything on the above form is true to the best of your knowledge.

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* 10. Date

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