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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 JUL 2 7 29V <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor `NVIRONMEWAL HEALTH <br /> P.O. Box 806 PERMIT/SERVICES <br /> Sacramento, California 95812-0806 <br /> 41 <br /> Month: v Year: c ,41 A)6j p1!AC VCW <br /> Name of scrap recycling facility: ,000xae go C/4 <br /> Facility address: `f✓�v A)' <br /> Name of CAR: JSP IVIMcX0 CAR # �{,x <br /> Total number of"orphan" appliances received this month (as indicated by use of DTSC <br /> Form 1459) received.- <br /> This <br /> eceived:This information is not required, but is appreciated: <br /> Space Heaters: Stoves: <br /> Refrigerators: Boilers: <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters.- <br /> Washers: <br /> eaters: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 ry Environmental Health&Safety <br /> R I C <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: Pbischoft>erger@usrscrap.com <br /> DTSC Form 1468(11/15/09) www.usrscrap.com Pago 1 of 1 <br />