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n <br /> State of California allfornia Environmental Protectlon Agency Department of Toxic Substanoes Control <br /> Orphan Appliance Monthly Repoij Form <br /> i Please send this document on a monthly basis to DTSC by Mpiling to; L VAttn: Consumer Products Section �, r <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology MAY 12 2017 <br /> 1001 "1" Street, 11th Floor <br /> P,O. Box 806 <br /> Sacramento, California 95812-0806 ENVIRONMENTAL HEALTH <br /> DFPAPTMENT <br /> Month: 11%X1 L Year: - kO/ 7 G� f�Ec yc zi A)1�/ <br /> Name of scrap recycling facility: v� V�Eft� <br /> A)Facility address. <br /> � <br /> ,✓2�e 0 . E�- po��p <br /> Name of CAR: (bJIV EA 0 L. -!51Eev11__6 a��C4A)gCAR # <br /> r N 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: oilers: <br /> Freezers: Furnaces: <br /> Microwaves: Water Heaters:. <br /> Washers: Air conditioners: <br /> Dryers: Trash compactors: <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 Bischofberger ...... <br /> Name ,y Environmental Health&Safety <br /> I i 209.944.9555 <br /> FAX:209•944.5552 <br /> CELL:209 855. 1715 <br /> Contact Informs 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischof erger@usrscrap.com <br /> DT$C Form 1468(1111 www.usrscrap.com Paye 1 of 1 <br />