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A' <br /> Department of Toxic Substances Control <br /> state of California—California Environmental Protection Agency <br /> Orphan i+uul6ance Monthly Repo„rt�F_or_m <br /> to DT b matting t" f= I <br /> V E D <br /> Please send this document on a monthly basis Y <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control 1PR 117 2017 <br /> Office of Pollution Prevention and Green Technology <br /> 1001 I" Street, 11 th Floor <br /> 8 <br /> P.O. Box 806 ENVIRONMENTAL HEALTH <br /> Sacramento, California 95812-0806 DEPARTMENT <br /> Month: J/iW0 )/ Year: ;;1,0 % /GSE E�yc z� � • AJ <br /> i <br /> Name of scrap recycling facility: v,v <br /> �2-e �. <br /> Facility address: C) � -- <br /> Name of CAR: 0,)1V ERexd1- S�RVK lir<<✓�gCAR # �6 3 <br /> 1.4v <br /> Ci <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: `��/�� Furnaces: <br /> Microwaves: j 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 /> 209.944.9555 <br /> FAX:209•944•5552 <br /> CELL 209.855. 1715 ......••• <br /> ............. <br /> Contact Inform, 3200 South El Dorado Street,Stockton,CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> DT8C Norm 1468(11/11 <br /> www.usrscrap.com Page 1 of 1 <br />