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State of California—California Environmental Protection Agency 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 RE1 <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11 th Floor JUL 2 12017 <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 cNVIRONMENTAL HEAI_��{ <br /> PEftnnlTrSERtlI('�c .;. <br /> Month: -JO�J iE Year: �:2.0/ <br /> sE7<vicC RAEC/'=4 •�'y . ��c <br /> �1)F1 '5 , <br /> Name of scrap recycling facility: � <br /> Facility address: <br /> Name of CAR: t2SA\ S �n`�E��d 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: heves-. <br /> Refrigerators: Boilers: <br /> Freezers: - Furnaces: <br /> Microwaves: - S Water Heaters: 4 `� <br /> Washers: / 17�3 Air conditioners: — <br /> Dryers: A5 3 Trash compacters: <br /> Ovens/s�UE- 1.3 3 <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 wV I Environmental Health&Safety <br /> P 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: Pbischotberger(Ousrscrap.com <br /> DTSC Form 1488(1/18/09) www.usrscrap.com <br /> Page 1 of 1 <br />