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r <br /> State of California—Callforn a znvironmental Protectlon Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> RECI Please send this document on a monthly <br /> bases to DTSC by mailing to: <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control <br /> ��t Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11 th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> Month: Year: 2,,::�> / <br /> Name of scrap recycling facility: -T tgooic'lls <br /> Facility address: S <br /> Name of CAR: ().SA Aqb9FS7T) 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: <br /> oilers: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 Bischofberger <br /> Name Iv Environmental Health&Safety <br /> L 1 L <br /> 209.944.9555 <br /> FAX:209•944•5552 <br /> ................................ CELL:209.855• 1715 <br /> Contact Information 3200 South EI Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger(i�usrscrap.com <br /> www <br /> .usrscrap.com <br /> DTSC Form 1468(1/16/09) Page 1 of 1 <br />