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State of Callfomla-California Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DISC by mailing to: <br /> ' Attn: Consumer Products Section WCEI <br /> �Department of Toxic Substances Control �� <br /> Office of Pollution Prevention and Green Technology JAN Q <br /> 1001 "1" Street, 11th Floor 2 2016 <br /> P.O, Box 806 <br /> Sacramento, California 95812-0806 ENVIRONW <br /> PE144i SFR HEALTH <br /> Month: ✓ Year: <br /> Name of scrap recycling facility: <br /> Facility address: <br /> Name of CAR: t,LSR S `v�E�f"o CAR # <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: 3 Water Heaters: 1 �> <br /> Washers: 6-1 Air conditioners: <br /> Dryers: v Trash compacters: <br /> Ovens: S� V.� J-d t t if—A`k; tJ <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 /> .._... _..._._....._.._— <br /> Universal Service Recycling, Inc. <br /> Paul, Bischofberger <br /> Name '..•.•,....•...•..• IV" I Environmental Health&Safety <br /> l 1 R <br /> o . 209-944-9555 <br /> FAX:209.944.5552 <br /> ........ <br /> CELL:209.85.5• 1715 .,.. <br /> ....................... <br /> Contact Information 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischotberger@usrscrap.com <br /> www.usrscrap.com Page 1 of 1 <br /> QT3C Form 1488(111 ti109) <br />