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P G .4 Z;5'- QL7 dAime4oN #Owa i <br /> State of California—California Environmental Protection Agency Department of Toxic Substances Control <br /> Form DTSC 1430 - Certified Appliance Recycler Waste Management Certification <br /> According to AB 2277(2004), a Certified Appliance Recycler(CAR) must remove and properly manage'materials that <br /> require special handling'from discarded major appliances. (HSC §25211) <br /> To document that the'materials that require special handling'were removed from major appliances prior to the appliance <br /> being crushed, baled, shredded, sawed, sheared apart or otherwise processed in a manner that could result in the release <br /> of these materials;scrap metal recycling facilities receiving appliances that have had'materials that require special <br /> handling'removed, must collect form DTSC 1430 at the time of transaction. Form DTSC 1430 is to be completed by the <br /> CAR that removed the materials that require special handling, not by the transporter. Form DTSC 1430 is a written <br /> certification signed by the CAR that'materials that require special handling'have been removed from the appliances listed <br /> below, in a manner that maintained compliance with subdivision (a)of Section 25212 of the Health and Safety Code. <br /> For appliance recycling information contact: (916) 324-3159. <br /> 1,) DTSC Certified Appliance Recycler(CAR) Number: Q) <br /> Please confirm CAR contact infonnation, associated with above CAR# C� ( I <br /> Name: ,-_,n -3%5 �C _/ sAI..0 A G e- 1Phone# (C{(C ) CnZ� -3-1( <br /> cj <br /> Address: ��Zy OO G d 1 I Ct r k4 P co Lt R T- Riy m cHD coqs)plJq l <br /> 2.) EPA Hazardous Waste Generator Identification Number: VO ?)E)5 6cu 3 96 <br /> (To obtain an EPA ID#complete form DTSC 1358) <br /> 3.) List the number of appliances next to the correct type for this shipment: <br /> Washer: Space Heater: Microwave: <br /> Dryer: Boiler: Oven: <br /> Refrigerator: :J� Furnace: Stove: <br /> Freezer: I Water Heater: Other: (please specify) <br /> Trash Compactor: Air Conditioner: <br /> 4.) List all facilities that the'materials that require special handling' removed from the above listed appliances <br /> were sent to, or the facilities where the materials will be sent: <br /> Type of material: Rn—zz- �--Re 1 ' r� 1 �/ <br /> t=== <br /> Facility information: 1:> 2RK1AN � U0.9,k �� W� 48Z-I"t (Please circle the appropriate: Materials have been sent <br /> Type of material:(- ,I� G(�CkLk -a9'S \ R e mcO6 UJ I NU IfZo N f�1en��L <br /> Facility information: Pv C VA4-4Ui ( - - S <br /> Please circle the appropriate: Materials have been sent or Material will be sent to <br /> Type of material: <br /> Facility information: <br /> Please circle th p ropriate. Materials have been sent or Material will be sent to <br /> I k����/)Oc�-n 2 <br /> ; CAR Name/Signature Dat <br /> C\ <br /> Transporter(i of CAR)/Signature Dat <br /> Signature of Person Accepting Shipment Date <br /> DTSC 1430(01/25/06)DRAFT <br />