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State of California California— Environmental Protection Agency <br /> Department of Toxic Substances Control <br /> Or an Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: <br /> Attn: Consumer Products SectionP%ECr- <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 ENVIRONMENTAL HEALTH <br /> Sacramento, California 95812-0806 PERPAiT/SFPV!^FS <br /> a ' <br /> Monthv�(�S Year: / 7 czi�Gj p�Gmew <br /> R�cY <br /> ,�� ��0 <br /> Name of scrap recycling facility: c��� �"/7 , <br /> vJJ. <br /> Tot <br /> -)Facility address: <br /> `�•� <br /> Name of CAR: JSRc CAR # `{;.2— <br /> Total number of "orphan" appliances received this month (as indicated by use of DISC <br /> Form 1459) received: <br /> This information is not required, but is appreciated: <br /> Space Heaters: Stoves: <br /> Refrigerators: Boilers: <br /> Freezers: Furnaces: <br /> 4� <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, ---..__.___w_--._.......... <br /> Universal Service Recycling, Inc. <br /> Paul Bischofberger <br /> Name IV I Environmental Health&Safety <br /> 209•944•9555 <br /> FAX:209.944•5552 <br /> ................................. <br /> CELL:209-855- 1715 <br /> Contact Information 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DTSC Form 1468(1116109) www.usrscrap.com Page 1 of 1 <br />