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T <br /> State of California toot California Environmental Protection Agency <br /> cepartment of Toxic 8ubatanoe$ Control <br /> Orphan A plias ge Monthly Report Form <br /> Please send this document on a monthly basis to OTSC by mailing to: <br /> ' Attn : Consumer Products Section <br /> Department of Toxic Substances Control <br /> Office of pollution Prevention and Green Technology <br /> 1001 " r Street, 11 th Floor <br /> P . O . Box 806 <br /> i Sacramento, California 9581211110806 <br /> Month : l �G Year : �o 7 _ � e y� z, AA r Aj, <br /> Lfl <br /> Name of scrap recycling facility : v S c - .$7 UCItfj�b N) )c— <br /> Facility <br /> Facility address : <br /> Name of CAR : vp / V E 5� � 6ERV 45 64vAN CARR # 563 <br /> 140VTotal number of "orphan" appliances received this month (as indicated by use of DISC <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 compactors : <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 COPA, <br /> Sincerely , <br /> Universai Service Recycling, Inc. <br /> Paul Bischofberger <br /> Name Environmental Health & Safety <br /> 209 . 944 . 9555 <br /> pAXI 209 . 944 . 5552 <br /> CELL, 209 . 855 . 1715 40 <br /> Contact informs 3200 South El Dorado Street, Stockton, CA 95206 <br /> &mail• Pbischofberger@usrscrap.com Page 1 of 1 <br /> DTI Form USS (1114 www.usrscrap.com <br />