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e <br /> 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 DTSCI� y D <br /> Attn: Consumer Products Section 0!�/ <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology OR 1 7 2017 <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 ENVIRONMENTAL HEALTH <br /> DEPARTMENT `6 <br /> Month: J/�,�v�l Year: �� / <br /> Name of scrap recycling facility: <br /> Facility address: <br /> Name of CAR: U5R S11'If ~� 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: �ttves: <br /> Refrigerators: I�k Boilers: <br /> Freezers: Furnaces: 6 <br /> Microwaves: �7-0 Water Heaters: // 7 <br /> Washers: Air conditioners: 1 <br /> Dryers: F-f Trash compacters: <br /> Oveng676VE 12-,5- <br /> Other (please specify):9Nffk), SffA ;7 \10A)91N� A/fCh`/A)E <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 /> R 1 <br /> r 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@usrscrap.com <br /> DTSC Form 1468(1/16/09) www.usrscrap.com <br /> Page 1 of 1 <br />