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State of California—California Envir ntal Protection Agency Del ent 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 b � <br /> Department of Toxic Substances Control 1�9 <br /> Office of Pollution Prevention and Green Technology JUL14 2016 <br /> 1001 "1" Street, 11th Floor <br /> P.O. Box 806 +=NVQ N74E <br /> PRS NTgL H <br /> Sacramento, California 95812-0806 ERAsIT/SEROCE$LTy <br /> Month: _J we Year: <br /> Name of scrap recycling facility: c��?(v E - � � l'� F <br /> .3 . � <br /> Facility address: � r='vr EL. -P&KAIWQ <br /> Name of CAR: 015 i� CAR # 53 '6"`7 S" <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 /> 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 E. Environmental Health&Safety <br /> . <br /> ]:El <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 /> DTSC Form 1468(1/16/09) www.usrscrap.com Page 1 of 1 <br />