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Stale 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 RECEIVED <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology G <br /> 1001 "1" Street, 11th Floor JUL 1 ��� <br /> P,O. Box 806 <br /> Sacramento, California 95812-0808 ENVIRONMENTgLHEA <br /> LTI­i <br /> SFR%ACE,c <br /> Month: Year: ;;ZD T <br /> c <br /> Name of scrap recycling facility: <br /> Facility address. <br /> Name of CAR: OPIVEA61S t' 7'c�✓'CgCAR # 6 <br /> 1 N C4 <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: j 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 supmltted to my CUPA, <br /> Sincerely, -- <br /> Universal Service Recycling, Inc. <br /> Paul Bischofberger ...... <br /> Name , Environmental Health&Safety <br /> 209.944•9555 <br /> FAX:209•944.5.552 <br /> CELL:209.855 1715 ..•..•. ...•..... <br /> Contact Inform, 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger®usrscrap.com <br /> DTSC Form 1488(1111 www.usrserap.coni Page 1 of 1 <br />