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State of California—Callforn——nvironmental 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: N+ I <br /> Attn: Consumer Products Section ImCcIVE0 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology JUL 2 l 2011? <br /> 1001 "1" Street, 11th Floor tNV1R0 <br /> P.O. Box Bos MENTAL HEALTH <br /> Sacramento, California 95812-0806 PERMIT/SERLICES <br /> Month: J 0 A) E Year: J_0/ <br /> Name of scrap recycling facility: UNC <br /> Facility address: .S?d S• f <br /> Name of CAR: VSA otaFS71D 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: 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 IV Environmental Health&Safety <br /> �a <br /> 209.944•9555 <br /> FAX:209.944.5552 <br /> ...................I....... ..... CELL:209.855• 1715 <br /> Contact Information 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger(a?usrscrap.com <br /> www <br /> .usrscrap.com <br /> DTSC Form 1468(1/16/09) Page 1 0}1 <br />