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P, RECEIVE <br /> Sime of Caldcrnra Cahrnrnla EnvnorNriwttal proled'onDEC 05 2014 <br /> Department of Toxic substances Control <br /> Form DTSC 1430 - Certified Appliance Recycler Waste Manageme <br /> According Ic AB 22;i g'fro a Carded Appliance Recycler(CAR)must remove and properly manage mater a sr tot HEALTH <br /> egwre special itandimg'from discarded major appliances {HSC§2521,1) <br /> i <br /> To document that the materials that require special handltng were roved from major appliances prior to the appliance <br /> being crushed baled, snreddeor sawed sheared apart or othervose p ocessed in a manner that could result In the release <br /> of these materials: scrap metal recycling facth(tes racelvmg appliances that have had 'materials that require special <br /> handling'removed. must collect form DISC 1430 at the time of transaction Form DTSC 1430 Is to be completed by the <br /> CAR that removed the materials that require special handling. not by the transporter. Form DTSC 1430 is a written <br /> ,:ertlfication signed by the CAR that materials that require special handling have been removed from the appliances listed I <br /> below, in a manner that maintained compliance with subdivision la�.of Section 25212 of the Health and Safety Code. <br /> For appliance recycling information contact (91 6) 324-3159. i <br /> 1 ) DTSC Certified Appliance Recycler(CAR) Number <br /> Please confirm CAR contact information. associated with above CAR 4 <br /> Name, Phone# <br /> Address /p5 0%r0/ <br /> 2.) EPA Hazardous Waste Generator Identification Number <br /> 1 to obtain at,cam.,,,,V complete form DTSC 1358) <br /> s) List the number of appliances next to the correct type for this shipment <br /> Washer Space Heater Microwave <br /> Dryer Boiler — Oven -- - <br /> Refrigerator _ Furnace. -7- Slove --- <br /> Freezer. Water Heater -T - — -- <br /> - _ Other (please specify) <br /> Trash Compactor -_ - _ Air Conditioner _ --- <br /> 4 1 List all facilities that the'matenals that require special handling removed from the above listed appliances <br /> were sent to. or the facilities where the materials will be sf:nt, <br /> Type of material <br /> r <br /> Facility information: �_o <br /> Please circle the appropriate: Matenals I lave been sant or- Mat at will be sent to <br /> Type of material: <br /> Facility information 1-�, t;Ya ir, - <br /> Please circle the appropriate: Malenals have been sent Of -Material will be sent to <br /> Type of material <br /> Facility information- <br /> Please circle the opri ate Uatenals ha,e beer sent or P.latenel anll be sent to <br /> i <br /> CAR r,13o,p Sig,jature � <br /> /t D fe <br /> -_S/tIT'. spert:r P, S.,_. ito, -- <br />