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• • <br /> State of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Form DTSC 1430 - Certified Appliance Recycler Waste Management Certification <br /> According to AB 2277(2004), a Certified Appliance Recycler(CAR) must remove and properly manage'materials that <br /> require special handling'from discarded major appliances. (HSC§25211) <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. / t� <br /> 1.) DTSC Certified Appliance Recycler(CAR) Number: I 1p (-3 <br /> Please confirm CAR contact information, associated withaboveCAR# <br /> Name: Phone# (�{K3R i <br /> Address: 'Zy OO Gold E tG Q co u SZ 4- 'RgN cH D co6Lc)Qilp <br /> 2.) EPA Hazardous Waste Generator Identification Number: (3(�p ?)FO S 6G <br /> 95 '12-6 <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: 1�ZZ �:Re- / <br /> Facility information: �RKtaty CAoL9,`<- . <br /> Please circle the appropriate: Materials have been sent d�Material will be sent to <br /> Type of material: �XC(—, --aC,'�to9's \- R P—M1�6 W 1s.N1/`1�0 N i'�1en'�flL <br /> Facility information: o V A Ut ( = 9 5 - -707 qqk ':PJ1 <br /> Please circle the appropriate: Materials have been sent or Material will be sent tc <br /> Type of material: <br /> Facility information: <br /> Please cir4CAR <br /> ropriate: Materials have been sent or Material will be sent to Name/Signature Dat <br /> I )� l ► � <br /> Transport (i not CAR)/Signature met 1 <br /> 1 <br /> Signature of Person Accepting Shipment Date <br /> DTSC 1430(01/25/06)DRAFT <br />