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State of California—Californi ironmental 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 ECF-:1VED <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 I'/r 6 <br /> Sacramento, California 95812-0806 <br /> ENVIRONI'VIENTAL <br /> Month: �" �_0AM-rRAENT <br /> Year: <br /> Name of scrap recycling facility: (,�,�,•v,���A ��,,�,f� ���.S , ,SIVA• <br /> Facility address: 3 Z o o 5'• F1 1,q <br /> �s �aG <br /> Name of CAR: SNe• CAR # 341- 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: 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 /> .......S- ,tw.rti...,s �.II X46 <br /> Name .....• <br /> Title <br /> ��?-o.`��• 51 . 9 .4lG.... . 20o S. !vo�,,�/� , �� <br /> Contact Information . ... .."".. ••�•e � -_-7� <br /> DTSC Form 1468(1/15/09) <br /> Page 1 of 1 <br />