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s <br /> State of California—California E )nmental Protection Agency <br /> partment 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 4.., <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology ¢001 13 2016 <br /> 1001 "I" Street, 11th Floor <br /> P.O. Box 806 = AfRobPIErur�H�Lr <br /> Sacramento, California 95812-0806 ERMITSERWCES <br /> Month: 141 A�l Year: 2>ZI' 6 <br /> Name of scrap recycling facility: <br /> Facility address: .3200 -. E-L 06KA4-4 5 Q s77� CA-19- <br /> Name of CAR: v-5& CAR # 0363 <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: C` <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,..... ... Unive <br /> ............ g, Inc. <br /> ""�������� <br /> Name <br /> Paul Bischotberger <br /> ,V` pp Environmental <br /> qp, e Health&Safety <br /> LING 209.944.9555 <br /> FAX:209. <br /> 944•5552 ................ <br /> Contact Inform; CELL:209.855 <br /> 3200 South Ell Dorado Street,Stockton, 1715 <br /> E-mai':Pbischo CA 95206 <br /> DTSC Form 1468(1/1 verger@usrscrap.com <br /> www.usrscrap.com Page 1 of 1 <br />