Laserfiche WebLink
Stale of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan 8pplliance Monthly Report Form <br /> Please send this document on a monthly basis to pTSC by mailing to. a <br /> Attn: Consumer Products Section , <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology JUN '12 2017 <br /> 1001 "1" Street, 11 th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 ENVIRONMENTAL HEALTH <br /> ',� DEPARTMENT <br /> Month: r/G` Year: ;;2,0 ?' <br /> Name of scrap recycling facility: v�/ KFC yc t��l � <br /> Y 9 <br /> Facilityaddress: -✓�� O `� E�' P0�(' p s s�Cl{ �� <br /> Name of CAR: v1J/V f,?�S� SERV�-_6 I�ECyC4A)gCAR # -3 <br /> r nv 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: Water Heaters:. <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: <br /> Ovens: <br /> Other (please specify): <br /> ,,he 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 supmitted to my CUPA, <br /> Sincerely, __.--- <br /> Universal Service Recycling, Inc. <br /> .,.... Paull Bischofberger <br /> Name , , Environmental Health&Safety <br /> 209.944.9555 <br /> FAX:209•944.5552 <br /> CELL:209.855• 1715 <br /> Contact Informi 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DTSC Form 1468(1/11 www.usrscrap.com Page 1 of 1 <br />