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�® g�� �Dep- ED <br /> Cah(Cmia � �a erns Eiwu Cpni- till Pralectmn-tyrn�y --:' o//�. //\' 1 <br /> Form DTSC 1430-Certified AppNance Recycler Waste Management Certification <br /> According ro AS 227740&1 a Certdied Appliance Re-- <br /> cfcler(CAR)must remove and properly manage'materials thaT '¢ <br /> require special handimg'from discarded major appliances (HSC§252111 <br /> To document that the'materials that require special handling were roved from major appliances <br /> pr�ENVIRONMENTAL R HEALTH <br /> being crushed baled. shredded, sawed sheared apart of otherwise p ocessed in a manner that could result in the release <br /> of these materials: scrap metal recycling tadtibes racernng 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 /> ,;ertification 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 lal of Section 25212 of the Health and Safety Code. <br /> For appliance recycling information contact 1916) 324-3159. i <br /> 1 ) DTSC Certified Appliance Racycler tCAR) Number <br /> Please confirm CAR contact information, associated with above CAR# <br /> Name: Phone A <br /> Address' /fJo2'S Q�a�R/ i� 1044c <br /> /-�r��� --- -'� <br /> 2.) EPA Hazardous Waste Generator identification Number fix/ <br /> i t o obtam a.C1 r.w N 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 - ` — <br /> oven <br /> Refrigerator Furnace: T Stove <br /> Freezer: Water Heater — -- <br /> Other (please specify) <br /> Trash Compactor _ - _ Air Conditioner ---- <br /> 4 ) 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 stint. <br /> Type of materiae C-" Z•. <br /> Facility information: ?-cam Ute. <br /> Please circle the appropriate: Materials IlEelve been sent or Material will be sent to <br /> Type of material: <br /> Facility information 1' . �k•lr, Cay ') y1• L> .\ r It <br /> Please circle the appropriate: Materials have been sent or Material will be sent to <br /> Type of matenal <br /> Facility information <br /> Please circle th opriate Materials t^a',e beer sent or P.latenai+,mif be sent to <br /> fd3"moi!/mature I <br /> Date <br /> -3 sper.;r C:1P. . Sic,^:u..: � Date <br /> _-_Signituie Cf h.::i'n.•:.ec'.I:I r'iinr ...._—. . .,_ .—, <br />