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State of California—California Environmental Protection Agency Department of ToXie Substances Control <br /> ,Orphan Appliance Monthly Report Form <br /> 1 .. <br /> Please send this document on a monthly basis to DISC by mailing to: n <br /> Attn: Consumer Products Section o —+ (� <br /> Department of Toxic Substances Control G <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor r <br /> Ro. Box 806 <br /> Sacramento, California 95812-0806 <br /> Month:sr✓ r7 Year: ;110 7 <br /> Name of scrap recycling facility: <br /> Facili address: ��-�' ` '� S .S7 Cly 7' �C <br /> Name of CAR. OJIVE-R50el- sERv'V"'6 1&yc4A)gCAR # <br /> 1N (4 <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 Bischotberger ...... <br /> Name iy Environmental Health&Safety <br /> t 209.944.9555 <br /> FAX:209-944 5552 <br /> CELL:209•855• 1715 „ <br /> Contact Informs 3200 South EI Dorado Street,SUx:klon,CA 95206 <br /> E-mail: Pbischofbcrgcr@usrscrap,c01n <br /> _ ..............,,,... 16M Oman 4 of 1 <br />