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Stale of Callfornla—Callfornla Environmental Protection Agency <br /> Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to D7 alfincl to; <br /> Attn: Consumer Products sect)ll� ED <br /> Department of Toxic Substances CoTbtr CEIV <br /> Office of Pollution Prevention and Green Technology <br /> 1001 1" Street, 11th Floor �O V 2 U 2017 <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> Month: &j obi_ Year: 2,,0 / 7 �� �Ec yc L/�/ 1 11,Name of scrap recycling facility: S"67A / <br /> sTDCI <br /> Facility address. <br /> C)��-e <br /> Name of CAR: UN/VF_A5V`1- 6 E9V cUA)gCAR # :�56 -� <br /> rN Q <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: jor <br /> Microwaves: Water Heaters:. <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: <br /> Ovens: �f <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 /> ......I............. Paul Bischofberger <br /> Name , Environmental Health&Safety <br /> -- 209•944•9555 <br /> FAX:209.944.5552 <br /> CELL:209 855 1715 <br /> Contact Inform; 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger((�usrscrap.com <br /> DT8C Form 1468(Illi www.usrscrap.com Page 1 of 1 <br />