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State of California—Californl ronmental Protection Agency Oepartment of Toxic Substances Control <br /> -rphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: RECEIVED <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology IAN 0 2 2018 <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 i;Nd IRONMENTAL HEALTH <br /> Sacramento, California 95812-0806 !)h:PARTIN1LNT <br /> Month: Year: <br /> Name of scrap recycling facility: UNC OF .5ApE— _g ISA VAC e Ar��c� <br /> Facility address: <br /> Name of CAR: v-Sj� Aq 4PE-5 CAR # —3ZAZZ::>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: <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 /> Universal Service Recycling, Inc. <br /> ................................ Paul Bischofberger <br /> Name r,..:k r Environmental Health&Safety <br /> x u;e <br /> v sane 209.944•9555 <br /> FAX:209.944•5552 <br /> ............................ CELL:209.855• 1715 <br /> Contact Information 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: PbischolbergerCa)usrscrap.com <br /> www.usrscrap.com <br /> DTSC Form 1468(1/18109) Page 1 of 1 <br />