Island Recycling, Inc.
COPPER SELLER’S STATEMENT
Under penalty of perjury, the SELLER certifies pursuant to Scrap Dealer Law §445-233, HRS, and
pursuant to the Copper Law, Act 197 (Session Laws of 2007), that the:
SELLER
SELLERS NAME (PRINT)
Is the lawful owner of the COPPER being sold as SCRAP to Island Recycling, Inc.. and further, as the
aforementioned SELLER, has the lawful right to sell and dispose of the COPPER as SCRAP..
SELLERS BUSINESS OR RESIDENTIAL ADDRESS (include City, State, Zip Code)
Use the lines provided above to describe, with particularity, the COPPER being sold as SCRAP
Who sold or otherwise transferred the item(s) to the SELLER (name and phone number)
Date of the sale/transfer of the item(s) _________________
Price paid (if any) for item(s) ________________
License number of any vehicle used to deliver the property to Island Recycling, Inc.
SELLER’s Signature
********************************FOR NOTARY USE ONLY*************************************
STATE OF HAWAII
}
SS.
CITY & COUNTY OF HONOLULU
}
On this
day of
20
, before me personally appeared
To me known to be the person described in and who executed the foregoing instrument and acknowledged
the person described in and who executed the same as his
or her free act and deed.
Notary Public Signature:
Print Name of Notary Public:
Notary Public, State of Hawaii
My commission expires:
L.S.
Doc Date:
# of Pages: 1
Notary Name:
Doc Description: Copper Sellers Statement
Notary Signature:
L.S.
L.S.