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State of California—California F '-onmental Protection Agency <br /> epartment 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 <br /> Department of Toxic Substances Control RECEIVED <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 MAR 2 6 2018 <br /> Sacramento, California 95812-0806 <br /> ENVIRONMENTAL HEALTF <br /> Month: 'r /'��� DI:RlkR INIENT <br /> Year: :�-� k �� <br /> Name of scrap recycling facility: N, �.A / ,5A�✓; M�i��C <br /> Facility address: Gf sU Al. Tv wEYZ Rei, Al E/lcE D� to 153 YO <br /> Name of CAR: "CE.D CAR # �eZZ <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: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: Trash compacters: <br /> Ovens: <br /> Other (please specify <br /> K- <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 /> .N 1r <br /> Name •-'L�....:5.... <br /> Title <br /> a <br /> Contact Information <br /> DTSC Form 1468(1/15/09) <br /> Page 1 of 1 <br />