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State of California—California Environmental Protecllon Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form M. <br /> Please send this document on a monthly basis to DTSC by mnoto: <br /> Attn: Consumer Products Section J1 <br /> Department of Toxic Substances Control �6' <br /> EU <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor , UIS 0 1 21ji,, <br /> j P,O. Box 806 <br /> Sacramento, California 95812-0806 NL70', 11AL f"-ITh <br /> P£MQDGE�s <br /> Month: Jv G X/ Year: -P,0 / <br /> rA <br /> Name of scrap recycling facility: v�/VFR�a9-�- " � <br /> Facility address: O �• �� ����p d s � s'"�Clt`�� �� <br /> Name of CAR: UN/UE�'S � SERo_-6 �gCAR # <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 Environmental Health&Safety <br /> Z_j* 209 <br /> .944.9555 <br /> FAX:209•944.5552 <br /> CELL: 209.955• 1715 <br /> Contact Inform< 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: PbischofbergerC@usrscrap.com <br /> DTSC Form 1468(1/11 www.usrscrap.com Pepe 1 of 1 <br />