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State of California—California Environmental Protection Agency Department of Toxic Substances Control Form DTSC 1430 - Certified Awiance 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: �)I C9 Please confirm CAR contact information, associated with above CAR#i Name: naSkN5 `QC eALV A G P- Phone# Address: 2y 00 C2 O d t—lqe co u 1— Roto cH p cops ql 1 2.) EPA Hazardous Waste Generator Identification Number: Ozp `,V 5 1pG 3 (To obtain an EPA ID#complete�R1� �I■VSE D 3.) List the number of appliances next to the correct type for this shipment: �Kl Washer: Space Heater: Microwave: Dryer: Boiler: oven: DEC 0 5 2014 Refrigerator: Furnace: 7:pr — Stove: Freezer: Water Heater: other: (please s�er�fi V1ROWMTAL HEALTH Trash Compactor: Air Conditioner: '`� TMENT 4.) List all facilities that the 'materials that require special handling' removed from the above listed appliances were sent to, or the(facilities where the materials will be sent: Type of material: R-2-,—;"ZZ F R Facility information: 2RKAN A U0.9,k ^ Please circle the appropriate: Materials have been sent o Material will be sent to Type ofmatenal:nllT AQr CAC,�\ 91S �= R e(1)c3o lJ G'NV �1 Facility information: Pg 01 cJG cJ Please circle the appropriate: Materials have been sent or Material will be sent tc Type of material: Facility information: Please circle th ropriate: Materials have been sent or Material will be sent to r CAR Name/Signature Date Transporter(i� f )/Signature Da e Signature of Person Accepting Shipment Date DTSC 1430(01/25/06)DRAFT