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1 <br /> State of California—CalifornI En,ronmental Protection Agency -opartment of Toxic Substances Control <br /> rphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: Inumm <br /> Attn: Consumer Products Section 1E® <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> J'� <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 ENWRON''MENTAL HEALTH <br /> Sacramento, California 95812-0806 PERMIT/SERVICES <br /> Month: ®�1�° 6p Year: c�-D/-9-- <br /> Name of scrap recycling facility: UNI U".S�— Sus�U�� � y«/^4i LAIC, <br /> Facility address: s <br /> Name of CAR: �S� K2FS� CAR # ��j <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: fd <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: <br /> Ovens: <br /> Other (please specify): zef <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 pIVP•Iµ 1^ Environmental health&Safety <br /> CHVI(e <br /> 209•944•9555 <br /> FAX:209•944•5552 <br /> CELL:209-855- 1715 <br /> .............I............... <br /> Contact Information 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischolberger@usrscrap.com <br /> www.usrscrap.com <br /> DTSC Form 1468(1/18/09) Pago 1 of 1 <br />