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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 '- <br /> .� <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11 th Floor JUN 12 2017 <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> ENVIRONMENTAL HEALTH <br /> �j� <br /> Month: DEPARTMENT i�'` Year: /� <br /> ` cam/ /A)C, <br /> Name of scrap recycling facility: (� II)F 6tfc '3 /{yie� Racy y' <br /> Facility address: <br /> Name of CAR: t,t5R Sr� `�E' CAR # 36-3 <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: 2— <br /> Washers: <br /> Washers: /Y Air conditioners: <br /> Dryers: 19,1 Trash compacters: <br /> Ovens/omvc : J rc) <br /> Other (please specify): j9j5I(L0pt!5,k`,w4; Id <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 nyeI Environmental Health&Safety <br /> C <br /> 1 209•944•955.5 <br /> FAX:209.944•5552 <br /> CELL: 209.855• 1715 <br /> Contact Information :1200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DTSC Form 14813(1/15/09) www.usrscrap.com <br /> Page 1 of 1 <br />