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State of California—Callfor.. -nvlronmental Protectlon Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DISC by mailing to: <br /> Attn: Consumer Products Sectionp <br /> Department of Toxic Substances Control &�did E <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor2 l 2016 <br /> P.O. Box 806KVIRn <br /> Sacramento, California 95812-0806 NMEKAL HEALTF! <br /> / PERMi1T/SERV70E:S <br /> Month: Na �/ Year: <br /> Name of scrap recycling facility: ITS(Ole F_ 9EIC-yf-`l&4/ ^�C <br /> Facility address: s?d s- Pte` 'S�!` yej!�PF_4"j <br /> Name of CAR: Vs� mea FSM CAR # ,.36-Z <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: 1 Boilers: <br /> Freezers: --- Furnaces: <br /> Microwaves: Water Heaters: <br /> Washers: Air conditioners: <br /> Dryers: _ Trash compacters: <br /> Ovens: — <br /> Other (please specify).- <br /> The <br /> pecify):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 /> ...........I.................... Paul Bischofberger <br /> Name uv Environmental Health&Safety <br /> . / [ _ <br /> 209.944.9555 <br /> FAX:209.944.5552 <br /> ................................ CELL:209.855• 1715 <br /> Contact Information 3200 South El Dorado Street,Stockton.CA 95206 <br /> E-mail: Pbischofberger@usrscrap.com <br /> www <br /> .usrscrap.com <br /> DTSC Form 1468(1/16/09) Page 1 of 1 <br />