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RECENE <br /> E-Waste Recovery Center I <br /> JAN 31 2014 <br /> Drop — Off Form ENVIRONMENTAI. <br /> Dear Valuable Customers, MEAL7H DEPAR WENT <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 f ' lJ �,'S' <br /> (Printed)COMPANY NAME <br /> If materials are used in company <br /> Street <br /> Printed your /6711 Re6 m. <br /> ADDRESS: 2 0 h.Ip� y n v(-( � m StbGl4tDh `�0106i--C <br /> STREET CITY/STATE/ a , <br /> ZIP CODE City State/Zip code <br /> 997 -- ,67616 63a2- <br /> PHONE NUMBER- <br /> CAResident Business El Educational <br /> CUSTOMER TYPE <br /> Non Profit El Government El Other <br /> ORDER# WAREHOUSE STAFF USE ONLY <br /> Received Qty Received Weight(LBS) <br /> CRT---Televisions <br /> CRT---Monitors <br /> LCDmonitors <br /> Laptops/Plasma <br /> "brand name,model#and serial# <br /> Computer System <br /> Other E Device <br /> (printer,keyboard,mouse,copier...) <br /> Other: <br /> Cell phone,battery... <br /> Warehouse Signature <br />