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State of California—Callfo,,a 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 Section11ECF-1 , <br /> Department of Toxic Substances Control "tea:, 47,,; <br /> Office of Pollution Prevention and Green Technology MAY <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 C_NVIROh,MEN-, U <br /> Sacramento, California 95812-0806 PERUIT/1-A; F.ALTH <br /> Month: /�— Year: /1-7 <br /> Name of scrap recycling facility: <br /> Facility address: <br /> Name of CAR: L25A SrCAR # <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: /8 <br /> Refrigerators: SD Boilers: <br /> Freezers: Furnaces: <br /> Microwaves: `�,e7 Water Heaters: /s-3 <br /> Washers: Air conditioners: <br /> Dryers: O;2, Trash compacters: l <br /> Ovens: 5 15JI.SravE. 1 qa <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 Environmental Health&Safety <br /> ,N� 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@usrscrap.com <br /> DTSC Form 1488(1/15/09) www.usrscrap.com <br /> Page 1 of 1 <br />