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State of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this docurnent on a monthly basis to DTSC by mailing to:RECEIV ED <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control 20%Office of Pollution Prevention and Green Technology .IAN O 2 <br /> 1001 "1"Street, 11 th Floor <br /> P.O. Box 806 r,NVIRO)NN►EN'VAL HEALTH <br /> Sacramento, California 95812-0806 t�h.P,�RThIENT <br /> Month: & z''L Year: / — c cti A) p�1nV<1_60 <br /> Name of scrap recycling facility: � - �� cv$ <br /> Facility address: Y,3�-a V. <br /> Name of CAR: J�'`R CAR # zj;Z 7, <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 compactors: <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 IV I Environmental Health&Safety <br /> 209.944.9555 <br /> FAX:209.944.5552 <br /> ................................... CELL:209.855. 1715 <br /> Contact Information 32(>n South FI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischotberger@usrscrap.com <br /> DTSC Form 1468(1/16!09) www.usrscrtp.com Pago 1 of 1 <br />