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GREENSDot DROPoff hT� COLLECTOR LOGS <br />Tracy Self Storage & RV Parking <br />free and convenient e - waste recycling #18898 <br />Fax o: C1ll <br />7Cn- � A1C e neatly fill out all fields. Your privacy is Important to us and your Information is not shared. The <br />tGW Pleaspurpose of the logs is to ensure compliance with all State and Federal regulations. <br />CALIFORNIA STATE REQUIREMENT <br />jj� ���_ �'' r� 1(Date: 7j -79 <br />Name/Business COucS'2�1L.r�l [) C"�A V Address -9S <br />Referred By J��� �City, State, Zip l�t `' 01' ( X <br />L� Z <br />! Phone Number ��762 Email lMQ-fWA0.OSofL�' CCCL <br />i � <br />i Circle or fill in the appropriate quantities <br />1 2 3 1 2 3 ��2_1.31 to 1 1 2 3 1 1121 3 1 2 3 <br />Computers Flat Screens <br />— L— <br />�9 <br />Tube Monitors Tube Televisions <br />CALIFORNIA STATE REQUIREMENT <br />Name/Business <br />Address <br />Date: —/2013 <br />I Referred By City, State, Zip <br />j Phone Number Email <br />I <br />Circle or fill in the appropriate quantities <br />1 1 2 1 3 1 1 2 1 3 1 1 1 1 2 1 3 1 1 1 1 2 1 3 1 1 1?I I 1? I I <br />f i e <br />Computers Flat Screens Tube Monitors Tube Televisions Laptops All Other E -Waste <br />GREENspot DROPoff, Inc. / 4712 W. Magnolia Blvd. Burbank, CA 91505 1800.350.3550 J info@greenspotdropoff.org <br />20:2.2 <br />Laptops <br />All Other E -Waste <br />Date: —/2013 <br />I Referred By City, State, Zip <br />j Phone Number Email <br />I <br />Circle or fill in the appropriate quantities <br />1 1 2 1 3 1 1 2 1 3 1 1 1 1 2 1 3 1 1 1 1 2 1 3 1 1 1?I I 1? I I <br />f i e <br />Computers Flat Screens Tube Monitors Tube Televisions Laptops All Other E -Waste <br />GREENspot DROPoff, Inc. / 4712 W. Magnolia Blvd. Burbank, CA 91505 1800.350.3550 J info@greenspotdropoff.org <br />20:2.2 <br />