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State of California—Callforn.__nvlronmental 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 x � <br /> Department of Toxic Substances Control YAM* ED <br /> Office of Pollution Prevention and Green Technology JUN 12 2017 <br /> 1001 "I" Street, 11th Floor <br /> P.O. Box 806 ENVIRONMENTAL HEALTIi <br /> Sacramento, California 95812-0806 PERMIT/,FRIACES <br /> Month: `'�j` Year: � / <br /> Name of scrap recycling facility: UNC UCS - -SlTjtUAcE <br /> Facility address: .s?d S- P` <br /> Name of CAR: VsA WaFSM 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 Bischoltberger <br /> Name ry Environmental Health&Safety <br /> ■ nc <br /> 209.944.9555 <br /> FAX:209•944•5552 <br /> ................................ CELL: 209.855• 1715 <br /> Contact Information 32(x)South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger(&usrscrap.corn <br /> DTSC Form 1468(1/15/09) www.usrscrap.com <br /> Page 1 of 1 <br />