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State of California—California Em nental Protection Agency rtment 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 ECEIVEU` <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "1" Street, 11th Floor MAR 2 6 201$ <br /> P.O. Box 806 <br /> Sacramento, California 95812-0806 <br /> ENVlROIUVENTAL <br /> Month: 'S flyv Year: <br /> Name of scrap recycling facility: J i _T�e <br /> Facility address: 9 -9-0 S. <br /> Name of CAR: ��,U,v,crsa/��rvrcc /Zec.7t.t:�j� _iw4 CAR # 3C,, 3 <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: j <br /> Washers: Air conditioners: f <br /> Dryers: Trash compacters: <br /> Ovens: / <br /> Other (please spec <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 /> Name Title <br /> .. S � <br /> .. <br /> Contact Information <br /> DTSC Form 1468(1/15/09) Page 1 of 1 <br />