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State of California—California ronmental Protection Agency apartment of Toxic Substances Control <br /> Orphan Appliance Monthly Report Form <br /> Please send this document on a monthly basis to DTSC by mailing to: Rt X <br /> Attn: Consumer Products Section ��1�1 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology ire 7016 <br /> 1001 T' Street, 11th Floor <br /> P.O. Box 806 `AIV/ROjVe4E,yT <br /> Sacramento, California 95812-0806 PERM'*' ���ALT-t; <br /> Month: /L Year: <br /> Name of scrap recycling facility: OA)N ��.':��; �.. `. '/�4 /c" E.=: lZ. -r YC:.4 iAj(? 1AJ( <br /> Facility address: _ i � .5� v"l.(� E [_.. ��4�X�r'xlcJ S 's_n c: <br /> Name of CAR: (>jCAR # ;`�' 3 j'4 <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 /> Name .,.•..•,.....•• Paul Bischotberger <br /> IV 1 Environmental ficalth&Safety <br /> R 1 R <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 1488(1/16/08) www.usrscrap.com <br /> Page 1 of 1 <br />