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State of California—California 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 bRE I E D <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control ;SPR 17 2017 <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11 th Floor <br /> P.O. Box806 <br /> ENVIRONMENTAL HEALTH <br /> Sacramento, Californiais 95812-0806 DEPARTMENT <br /> Month: FoE?1YCW Y Year: 70/ <br /> Name of scrap recycling facility: <br /> Facility address: <br /> Name of CAR: U56 S�� E�v~� 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: 6 Boilers: <br /> Freezers: Furnaces: <br /> Microwaves: J�? Water Heaters: 1 <br /> Washers: 1s3 Air conditioners: <br /> Dryers: / -77 Trash compactors: --- <br /> Ovens: 1,z/ 7 <br /> Other (please specify): D/Sft t.Df_s1-,1E4C ��q <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 2:3: nV Environmental Health&Safety <br /> C , 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@usrserap.com <br /> DTSC Form 1468(1/15/09) www.usrscrap.com <br /> Page 1 of 1 <br />