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State of California—California Er mental Protection Agency artment of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing <br /> Attn: Consumer Products Section ��4 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology MAR 2 6 2018 <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 ENVIRONMENTAL <br /> :-,C0APTAAFNT <br /> Month: j Year: 21 <br /> Name of scrap recycling facility: <br /> Facility address: .5-20 0 6. 5W. S��e/ A,.v, 1A 9 s 20 <br /> Name of CAR: G�iv;�uS.4l SGrv:e</1.c���l,�s, S-ve. CAR # 3 6 3 <br /> Total number of `orphan" appliances received this month (as indicated by use of DTSC <br /> Form 1459) received: <br /> This information is not required, but is appreciated: <br /> Space Heaters: Stoves: <br /> Refrigerators: Boilers: <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: T7 <br /> Ovens: <br /> Other (please specify): <br /> The names and addresses of each person who transported, delivered, or sold "orphan" <br /> appliances to this scrap recycling facility is included on the following additional pages. <br /> This information has also been submitted to my CUPA. <br /> Sincerely, <br /> -10 <br /> 5 16-1-115 <br /> Name Title <br /> �S ���, <br /> Contact Information . <br /> DTSC Form 1468(1/15/09) <br /> Page 1 of 1 <br />