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1 <br /> State of California—Californl En\ronmental Protection Agency Lpartment of Toxic Substances Control <br /> rphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: <br /> Attn: Consumer Products Section > <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology �e. .i J 2alt f,., <br /> 1001 "I" Street, 11th Floor r- <br /> Sacramento,P.O. Box 8a 95812-0806 06 ENV ROWENTAL HEALTH <br /> 11ERMl_F/SERI/!1ES <br /> Month:� Year: �/� 7 <br /> Name of scrap recycling facility: OPV" <br /> Ste— <br /> v"A <br /> Y <br /> Facilit address: <br /> Name of CAR: V-Sr\ �tttPFS� CAR # <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 compacters: <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 Bischofberger <br /> Name grvr. Environmental Health&Safety <br /> .,,NG 209.944•9555 <br /> FAX:209•944•5552 <br /> CELL:209.855• 1715 <br /> ...................... <br /> Contact Information 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail:Pbischofberger@usrscrap.com <br /> www.usrscrap.com <br /> DTSC Form 1468(1/18/09) Page 1 of 1 <br />