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State of California—California Environmental Protection Agency Department of Toxic Substances Control Form DTSC 1430 - Certified Appliance Recycler Waste Management Certification According to AB 2277(2004), a Certified Appliance Recycler(CAR) must remove and properly manage'materials that require special handling'from discarded major appliances. (HSC§25211) To document that the 'materials that require special handling'were removed from major appliances prior to the appliance being crushed, baled, shredded, sawed, sheared apart or otherwise processed in a manner that could result in the release of these materials; scrap metal recycling facilities receiving appliances that have had 'materials that require special handling' removed, must collect form DTSC 1430 at the time of transaction. Form DTSC 1430 is to be completed by the CAR that removed the materials that require special handling, not by the transporter. Form DTSC 1430 is a written certification signed by the CAR that'materials that require special handling' have been removed from the appliances listed below, in a manner that maintained compliance with subdivision (a) of Section 25212 of the Health and Safety Code. For appliance recycling information contact: (916) 324-3159- 1.) DTSC Certified Appliance Recycler(CAR) Number: Q) G4� Please confirm` CAR contact information, associated with above CAR# C p Name: I Q�p 5 \(A c- -1 rjA�,.,�Jt,� G e- 1 - Phone# (CA r. CjZ� �3-l) Address: �'ZLA OO C20 1 d r(ca ke co u R-�- 9wkw CHD C-0'e miq 2.) EPA Hazardous Waste Generator Identification Number: (31z0 NE)5 tpG 95 -� y2-67 (To obtain an EPA ID#complete form DTDTSC C1 8)13 ) 3.) List the number of appliances next to the correct type for this shipment: • i L V E I VED Washer: Space Heater: Microwave: Dryer: Boiler: Oven: Refrigerator: Furnace: Stove: Freezer: �T Water Heater: Other: (please specify) OF r 05 2014 Trash Compactor: Air Conditioner: 4.) List all facilities that the 'materials that require special handling' removed from the above IisF4WPWENTAL HEALTH were sent to, or the facilities where the materials will be sent: DEPARTMENT Type of material: ZZ F R Facility information: !?) e2KIAty A C�aRK 7p-1 �nlA 1p24,40q Please circle the appr1opriate: Materials have been sent � Material will be sent to y' Type of material:(-�X l�pA Lktn9's R 4;-� M(30 W GNU 1e0 N MCR 1 4AL Facility information: p V 9 —4A U i I I 9 C 5 — 30-7 LU16 3D 0 Please circle the appropriate: Materials have been sent or Material will be sent to Type of material: Facility information: Please circle thropriate: Materials have been sent or Material will be sent to /lOc%n 2 /14 04 CAR Name/Signature Dat I Transporter(I of-CAR)/Signature Dat Signature of Person Accepting Shipment Date DTSC 1430(01/25/06)DRAFT