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State of California—California Em cental Protection Agency l tment of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC bailing toL: .: ,� � gED <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control G E <br /> Office of Pollution Prevention and Green Technology FEB o 5 2018 <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Month: �(� Year: � R <br /> Name of scrap recycling facility: ifN,-VX r$1A/ cSL/vIA8 t0-9�%"S . ?Ve. <br /> Facility address: 3-200 ,S��We V4PN,, Vf S .2 o G <br /> Name of CAR: .Z-Ne• CAR # -343 <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: 10 Stoves: f7-1 <br /> Refrigerators: Boilers: �y <br /> Freezers: q6 Furnaces: /all ' <br /> Microwaves: �01 Water Heaters: <br /> Washers: ( L Air conditioners: <br /> Dryers: t S Trash compacters: eor <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 /> -��N. ...,��.�. .......... .. /?!r <br /> Name Title <br /> 99 ......3 ZOo S. c'/D!r, i ,S� <br /> Contact Information <br /> DTSC Form 1468(1/15/09) Page 1 of 1 <br />