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State of California - California Environmental Protection Agency <br /> Department 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 <br /> Department of Toxic Substances Control <br /> Office of Pollution Prevention and Green Technology <br /> 1001 "I" Street, 11th Floor <br /> P. O. Box 806 <br /> Sacramento, California 95812-0806 <br /> Month , Year: . - <br /> Name of scrap recycling facility: acv; VX r psi / cftrVs e e /& cj 44ul , ,,,tove • <br /> Facility address : 3747 ® F1 Dor4dy Slew ,S'yv c/ v,, 1r4 s 2 ® G <br /> Name of CAR: (,IAPT ✓,ctSAl. eryje.R /�ed�+ r 7�.r, .,Twe, 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 /> mamma . . . . . . . . . . few <br /> . . . . . . . . . <br /> Name "S Iu V a 0 a <br /> Title <br /> 4!�. . . . . .. ?�?�? S. 4r orale , . � � <br /> Contact information ' <br /> DTSC Form 1468 (1/15/09) <br /> Page 1 of 1 <br /> I <br />