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ECS Refining <br />trTANAGEMENT SYSTEM DOCUME <br />Appliance Recycling SOP <br />page 14 of 14 <br />Stale of Califana-CaBfema Enwonmemal ProfeuYlon Agency Department of-Imic Substances COM01 <br />Orphan Appliance Monthly Report Form <br />Please send this dommilent on a monthly basis to DTStion by mailing ECEIV E© <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 MAY 18 2015 <br />P.O. Box 806 <br />Sacramento, California 95812-0806 ENVIRONMENTAL <br />HFAI.TH nrpi ..TIIII <br />Month: Year: <br />Name of scrap recycling facility: <br />Facility address: <br />Name of CAR: <br />CAR ft <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: <br />Refrigerators: <br />Freezers: <br />Microwaves: <br />Washers: <br />Dryers: <br />Ovens: <br />Other (please specify): <br />Stoves: <br />Boilers: <br />Furnaces: <br />Water Heaters: <br />Air conditioners: <br />Trash compacters: <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 />............................................. <br />................................. . <br />... <br />Name Title <br />Printed copies are uncontrolled. <br />This copy valid only if revision letter matches that of controlled document <br />