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State of Callfornia , California Emrironrmntal Protection Agency Department of Toxic Substances Control <br /> Orphan Appliance Monthly Report Fortlh <br /> Please send this document on a monthly basis to DTSC by math g ' ' <br /> Attn: Consumer Products Section <br /> Department of Toxic Substances Control b , <br /> Office of Pollution Prevention and Green Technology � �1 <br /> 1001 " 1" Street, 11th Floor <br /> P .O . Box 806 EVVRO NMEWIAL HEALTH <br /> Sacramento, Califomis 95812-0806 <br /> c: alt `- i1.4 . ,. <br /> Month . riN Year: <br /> Name of scrap recycling facility : a,4v, ver9A / X40wvl " t& ej44>jj <br /> Facility address: 32400 S. E/ U®r4rob 5 ( S1 414 Amo 1A IP S a 4 G <br /> Name of CAR : (.11w ✓ZorXAr YAriV1 dA ,f, �✓`• 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 . 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 /> Name Title <br /> :;'WSW/ <br /> Contact Information <br /> DTSC Form 1468 (1/15109) Page 1 of 1 <br /> E <br />