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E-Waste Recovery Center <br /> Drop — Off Form <br /> Dear Valuable Customers, <br /> Under California State Recycling regulations, In order to provide you a FREE SERVICE for <br /> recycling, please fill out your TRUE information as following for California state verification <br /> purposes. <br /> Thank you for your efforts on saving the environment. <br /> CONATCT PERSON _�} DATE <br /> FIRST NAME/LAST NAME .r— <br /> (Printed)COMPANY NAME <br /> If materials are used in company <br /> Street <br /> Printed your 1`, X11Rd 6o o-n. 64""`t'- <br /> STREETADDRESSTATE/ O Wi pYVIQ41fi" i'VyVV� �Y W1 W(,y-tDVl <br /> ZIP CODE City State/ Zip code <br /> PHONE NUMBER- <br /> CA Resident Business Educational <br /> CUSTOMER TYPE <br /> Non Profit El Government 0 Other <br /> ORDER# WAREHOUSE STAFF USE ONLY <br /> Received Qty Received Weight(LBS) <br /> CRT---Televisions <br /> CRT---Monitors f <br /> LCDmonitors <br /> Laptops/Plasma <br /> .. <br /> *brand name,model#and serial# <br /> Computer System <br /> Other E Device <br /> (printer,keyboard,mouse,copier...) <br /> Other: <br /> Cell phone, battery... AN 3 1 2014 <br /> Warehouse Signature I <br /> HEALTH DEPARTMENT <br />