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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: <br /> Please j <br /> confirm CAR contact information, associated with above CAR# <br /> Name: —aL-�N5 IA C- 1 �jr- �c�L-Q A c, e- 1- Phone# EK) p 2,1 -3% <br /> Address: 1 Z'AOO G O lla �G P sA R-t' RAN cH cap-min <br /> 2.) EPA Hazardous Waste Generator Identification Number: 0m IFO 5 6G3 <br /> 9S � ZC7 <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: �_ Furnace: Stove: <br /> Freezer: 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 /> c <br /> Type of material: ��—�—Z rR <br /> Facility information: �j 2EZK AN U 0.� 1 I w l U2��acl <br /> Please circle the appropriate: Materials have been sent Material will be sent to <br /> Type of material:(-�I,T,Q lic"kt )IS e-Mi0 w F-WV'k?-o N f' Ae 4� L <br /> Facility information: go V +Au( ( = c S — -767 3��J <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 /> CAR Name/Signature Date' <br /> Transporter(if n, ! )/Signature Date <br /> Signature of Person Accepting Shipment Date <br /> DTSC 1430(01/25106)DRAFT <br />