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State of California—California Envental Protection Agency E. tment of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: <br /> Attn: Consumer Products Section �-- IVED Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Techn o C11 <br /> 1001 "1" Street, 11th Floor <br /> �� ® 5 2018 <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> ENVIRONMENTALHEALTHALTH <br /> Month: Q Year: ?-0 �- DEP <br /> Name of scrap recycling facility: (,�Alt V.l r Iia ,S<✓✓%a< ��y��%'�} /�s��� <br /> Facility address: 1-15V Al. Tv WM Rel, Ai ERee Dl ZR q 53 YO <br /> Name of CAR: U $ R It4 "CE,rj CAR # FIZZ <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: <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 /> �.......... ..�'NS.:� �.!. ..y':.. <br /> Name Title <br /> 64 fsZ o <br /> Contact Information <br /> DTSC Form 1468(1/15/09) Page 1 of 1 <br />