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I : ' ta �`a <br /> Please pant or type.(Form designed for use on elite.(12-pit�ypewrd % �s er) t;,. ���� i Farm Approved.OMB No.2050-0038 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Ma Nest rackhri Nu ben (y <br /> WASTE MANIFEST CALt, 0270@Yb 7 209.4 -1477 0231,71259 G B F <br /> 5.Generator's Name and Mailing Address J H SIMPSON CO Generators Site Address(R different than mailing address) <br /> 4025 CORONADO AVE <br /> STOCKTON,CA 35204 <br /> Generators Phone:209-4168-1477 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OIL,INC. CALCUM27i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 114ddc�� �, � r� 1�I aC unu i u C C-�'o kff¢7 <br /> B.Designated FadliryName and SkaAddress 21ST bENITURYENIVIRONMENTALMOM NEVADA,LLC U.S.EPA ID Number <br /> 2095NEWLANIDSDR.EAST <br /> FFRNLEY,NV 69108 <br /> Facility's Phone: 775675.2750 <br /> ga, 91d.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group if any)) No. Type O Totalntity Wt.Nol. 13.Waste Codes <br /> s 1. NAd062 WAZARDOUS WASIE,LKUD,N.O.S.9 FK3111 � F�1 gg � G 00111 222 1 <br /> o gr3F FFRiDGERATOIN OIL WITH TRACES OF FREON) _- -- <br /> fz 2. <br /> E <br /> 3. <br /> DCO <br /> 4. <br /> E VIRON EN IL H ALT <br /> DE ART ENT <br /> 14.Special Handling Insuuctions and Additional Information <br /> PIcOFILF# 402S4-W-REFER OIL WITH TRACES OF FREON <br /> &KW W, <br /> EMERGEi CCt3W TACT-ROBERT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gerrerator)or(b)(if I am a small quantity generator)is We. <br /> GeneretorslOfferors Priated/Fyped Name , Signature Month Day Year <br /> ri6 International Shipments <br /> H ❑Importto U.S. ❑Export from U.S. Port of entrylexit: <br /> M Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> oTranspo 1 Pri t /Typed Name / Signature Month Day Year <br /> 1 fY � ) <br /> Q Trans erg ted yped erne g Mo a Year <br /> Si re <br /> ` 4 \ ' ' <br /> 11 18 Discrepancy''. _ <br /> 182 Discrepancy Indication Space ❑ ❑Partial Rejection El Full Rejection <br /> Quantity ❑Type ❑Residue <br /> ifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> has the appropriate permit(s) <br /> LL Facility's Phone: <br /> w 18c.Signature ofNtemate Facility(or Generator) <br /> tR z this g8f16 al is shipping. Month Day Year <br /> _. <br /> Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1 2. 3. <br /> 1 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 182 <br /> PrintedRyped Name_,., � Signature Month Day Yeah <br /> EPA Form.8700-22(Rev.3-05) Previous editions are obsolete. - 03-10-14P] 2 :5,7 R CVD. DESIGNATED FACILITY TO GENERATOR <br />