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State of California—Callt. .Environmental Protection Agency Department of Toxic Substances Control <br /> Orphan Appllance Monthly Report Form <br /> _N1=Please send this document on a monthly basis to DTSC Pfifing t <br /> Attn: Consumer Products Section , 1VED <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology MAY 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: L Year: ;,--) / <br /> Name of scrap recycling facility: UNr U9KSALc-- .S liSA DACE RZr_j e-Q&4� <br /> Facility address: <br /> Name of CAR: VsA Jq49FSM 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, b is appreciated: <br /> Space HeStoves: <br /> Refrigerators: 3 Boilers: <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: <br /> Ovens: <br /> Other (please speci ): <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 Bischotberger <br /> Name Iv Fnvironmental Health&Safety <br /> X� ■ I it <br /> 209•944.9555 <br /> FAX:209.944.5552 <br /> ........................... CELL:209.855• 1715 <br /> Contact Information 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DTSC Form 1468(1/16/09) www.usrscrap,com <br /> Page 1 of 1 <br />