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State of California-California En,`-nmental Protection Agency <br /> >artment 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 Section RECEIVED <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11 th Floor MAR 2 6 2016 <br /> P.O. Box 806 LNVIRONnIL'N 1'AL IIFAL"[H <br /> Sacramento, California 95812-0806 <br /> D1;1'.%10"NICN7' <br /> Month: Year: <br /> Name of scrap recycling facility: /s/.Creeee <br /> Facility address: 4/5V Al. -rU t,. FR- Rei, <br /> Name of CAR: LC 5 2 /Yj "eFp <br /> CAR # "2 <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: 1. <br /> Refrigerators: Boilers: }� <br /> 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 personwho 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 /> ��:��......5....... <br /> Name ........... Z�iy,S. <br /> Title <br /> ..7 "1.-. .�i'(......3.200..5.... 1.�►! Six' s2o <br /> Contact Information � ... <br /> DTSC Form 1468(1/15/o9) <br /> Page 1 of 1 <br />