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State of California—California 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 DTSC by mailing to: <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology ;� IV <br /> 1001 'T' Street, 11th Floor <br /> P,O, Box 806 SEP 1 0 20J <br /> Sacramento, California 95812-0806 <br /> ENWIRONMEN rAL HEALTH <br /> 7 PERMIT/SERIACFS <br /> MonthU�j v7` Year: / i/JC. <br /> Name of scrap recycling facility: <br /> Facility address: <br /> Name of CAR: t,ZS� S X/ Ei� CAR # �3 <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: <br /> Refrigerators: '� Boilers: .— <br /> Freezers: Furnaces: <br /> Microwaves: c?2, Water Heaters: Z- <br /> Washers: 29,5_ Air conditioners: <br /> Dryers: 2,T7 Trash compacters: <br /> Ovens/:47b 0E ;7,7s� <br /> Other (please specify): /s/ � R /s� <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 /> ................... <br /> Sincerely, <br /> Universal Service Recycling, Inc. <br /> Paul Bischofberger <br /> Name nvn � _ Environmental Health&Safety <br /> . , R <br /> 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 Page 1 of 1 <br /> DTSC Form 1468(1116/09) <br />