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State of California - California Environmental Protection Agency Department Of Toxic Substances Controt <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 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 " 1" Street, 11th Floor <br /> P .O . Box 806 <br /> Sacramento, California 95812-0806 <br /> Month : Year: <br /> Name of scrap recycling facility : UA1, vt ! 04 / SSzrv/ cl j0's - -rVe , <br /> Ao <br /> Facility address : 3700 5 . El t� �r �rly clovr (A s <br /> Name of CAR: 1,V; V"X41 j1de-.0 04S , e• CAR # 343 <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 : f Stoves : <br /> Refrigerators : S Boilers. <br /> Freezers : Furnaces : <br /> Microwaves : Water Heaters : <br /> Washers: l Air conditioners : , <br /> Dryers : I 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 /> 05, <br /> Name Title <br /> Contact Information <br /> DISC Form 1468 (1115109) Page 1 of 1 <br />