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• • RECEIVED <br /> State of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Form DTSC 1430 - Certified Appliance Redycler Waste Management Certpk6tYO0oii 2014 <br /> According to AB 2277(2004), a Certified Appliance Recycler(CAR) must remove and prope UV fd ATAbMEA TH <br /> require special handling'from discarded major appliances. (HSC §25211) DEPARTMENT <br /> To document that the'materials that require special handling'were removed from major appliances prior to the appliance <br /> being crushed, baled, shredded, sawed, sheared apart or otherwise processed in a manner that could result in the release <br /> of these materials; scrap metal recycling facilities receiving appliances that have had 'materials that require special <br /> handling'removed, must collect form DTSC 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 /> certification signed by the CAR that'materials that require special handling' have been removed from the appliances listed <br /> below, in a manner that maintained compliance with subdivision (a) of Section 25212 of the Health and Safety Code. <br /> For appliance recycling information contact: (916) 324-3159. p <br /> 1.) DTSC Certified Appliance Recycler(CAR) Number:— 0I (�00 <br /> Please confirm CAR contact information, associated with above CAR# c� <br /> Name: I'a 415 'QC 1 ryALU A G e- 1 Phone# (SK) <br /> Address: ,Zy OO C Old CUR 1` FZgNC1-1� CO Oi��Fa t <br /> 2.) EPA Hazardous Waste Generator Identification Number: 611�p 95 x'120 <br /> (To obtain an EPA ID#complete form DTSC 1358) <br /> 3.) 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: Stove: <br /> Freezer: Water Heater: Other: (please specify) <br /> Trash Compactor: Air Conditioner: <br /> 4.) List all facilities that the 'materials that require special handling' removed from the above listed appliances <br /> were sent to, or the facilities where the materials will be sent: <br /> Type of material: R-2-;—"' F P p <br /> Facility information: is -RK4NM Ua(ZK <br /> Please circle the appropriate: Materials have been sent Material will be sent to <br /> Type of material:(- IJ(��L�tC)9,rj e(N)oo NV`tizo <br /> Facility information: o V Ar-'A U t - Ci C 5 -70-7 q , 3�00 <br /> Please circle the appropriate: Materials have been sent or Material will be sent to <br /> Type of material: <br /> Facility information: <br /> Please circle th r <br /> ropriate: Materials have been sent or Material will be sent to <br /> 7 �— <br /> CAR Name/Signature Dateir <br /> Transport (i not CAR)/Signature at <br /> Signature of Person Accepting Shipment Date <br /> DTSC 1430(01/25/06)DRAFT <br />