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State of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report FormIf <br /> n� <br /> t <br /> Please send this document on a monthly basis to DTSC by mailing to: 1L W..-f <br /> Attn: Consumer Products Section NOV 2 0 2017 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Techno1g9NV/RO <br /> 1001 "1" Street, 11 th Floor NME� A1_ <br /> P.O. Box 606 DEPARTMEN r _ H <br /> Sacramento, California 95812-0806 <br /> Month: o__ // Year: �/� Gz1.c16j p��cw <br /> �t�� s� rCy <br /> Name of scrap recycling facility: 0A)i>,� <br /> �c <br /> Facility address: �' <br /> Name of CAR: JSRc CAR # x{02 <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: Ile <br /> Refrigerators: Boilers: /40' <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: Trash compactors: <br /> Ovens: <br /> Other (please specify): or <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 COPA. <br /> Sincerely, _._.._..__... ._...._ . — <br /> Universal Service Recycling, Inc. <br /> ....... ........ Paul Bischofherger <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(x)South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DTSC Form 11468(1115109) www.usrscrap.com Pago 1 of 1 <br />