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n <br /> Stale of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> R <br /> .yamV E E <br /> Please send this document on a monthly basis to DTSC by mailing to: <br /> Attn: Consumer Products Section AUG 0 7 2017 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1"Street, 11th Floor ENVIRONMENTAL HEALTI- <br /> P.O. Box 806 DEPARTMENT <br /> Sacramento, California 95812-0806 <br /> Month: Jv L Year: R,�cYcLi Aj <br /> )010F s <br /> Name of scrap recycling facility: (' n � CW <br /> Facility address: y,56 V. 7oc`-� dC <br /> Name of CAR: 05R CAR # J(;Z 7.., <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 Bischofberger <br /> Name w I Environmental Health&Safety <br /> R I E <br /> 209•944•9555 <br /> FAX:209.944.5552 <br /> ......................... CELL:209.855• 1715 <br /> " Contact Information 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger4usrscrap.com <br /> DTSC Form 1468(1/16109) www.usrscrap.com Page 1 of 1 <br />