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Please print or type.{form designed form on elite(11-pitch)typewriter.) f (-�,r rl .,'tel �f l-_. Form APProved.DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Garerator 10 Number 2.page 1 of 3.Emeryency Response Phone 4.Maeilest Tres nq r <br /> WASTE MANIFEST CALOW279478 1 209.46&1477 l� eZ g G B F <br /> 5 Genamlols Name and M1ki9ng Address Generator's Sao Accress In comeeal bar mailing addiess) <br /> J H SIMPSGN co <br /> 4025 CORONADOAVE <br /> STOCKTON,CA 95204 <br /> Generators Pirone.2L'8-466-1477 <br /> 6.Talismans,1 Company Name US EPA N Numbar <br /> AMERICAN VALLEY WASTE OIL. RX: CAL000827676 <br /> I iBnsppder2 Company Name 1 U.S.EPAIDNumW <br /> 21 `' fc(�k - ii If ctiIr It-gI wph I f, ( C 'Wq/L6r7 <br /> 8.Devgnaled Facky Name and arm Address 21 ST CENTURY ENVIROMMIENiAL MGM fNE:VADA,LLC US EPAIDNumber <br /> 2095 NEWLAND5 DR EAST NVD980895338 <br /> FERNLEY.NY 89406 <br /> 77`5.575-2780 <br /> Fatenys Plgm: <br /> ga 9b.U.S DOT DesaroW(indudag Roper Shipping Name.Hazard Can,10 Number, 10.Corld"m 11.Toe 12 Unit <br /> HM and Pao irp Group(famy)) Na. Type Ouanoly i"01. 15.Wells Codes <br /> a l t4A3082 HAZARDOUS WASTE,LIOJID,N.O.S.8 PGIII ,rte DM G Fb01 22:9 <br /> rREFRiDGERATOIN OIL WITH TRACES QF FRFON) <br /> z 2 <br /> w <br /> i <br /> b <br /> 1 <br /> 14 Spea ll Handling InSVasfWS arld Additional hdormation <br /> PROFILE M 40234-00-REFER CIL WITH TRACES OF FREON <br /> ERGs III <br /> EMERGEN CONTACT ROBERT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare thal the contents of this conspnment are fully am accurately desrnbed above by the proper shipping rame.are are classified,packaged, <br /> marked and IabeleNplecarded,and are in all respects In Poem conygon for transport according 10 apphiable mu mahonal am natbnal govenmenlzl mil k sra 11 expon shipmsA and I am the Primary <br /> Exporter I cerofy that the mntenls of INS Consgmment coelom to the temis of the attached EPA Adm lsdgrm nl of Consent. <br /> I comfy That the wamle rmnsn'vaturr statement ideMAied in 40 CFR 26127(x)pl I am a large quantity generator)or(b)(di am a smaa quarsiy,genealorl m true. <br /> GenerawsrOgoors Noted/Typed Name Signature 1 Month Day Year <br /> J16. mNndtgnal$hipnenls <br /> ❑ImpotbUS. ❑EYpoR from US. Par.(enU.S.!Transporter signature(for rumors mly): Dale leaving <br /> U. .. <br /> w 17.TransponerAAno%4edgmentofRe plat Matdna5 <br /> OTra 1 P' tryped Name S19mbu / Morin Day Year <br /> Tamscichair 2 tM yped Nam Sig Mm ay Y <br /> ew <br /> i16 Dlzcnepancy 5 U, <br /> 10a.Dscmancy mdinfon Space Qenury ❑TyceBud Re)ecoon <br /> ❑Resque ❑Penia!Reeccon <br /> nest Refineries Numbs: <br /> 1M AttarNre FaCtlAylcr Genemtoq U.S EPA 10 Number <br /> u has the appropriate permit(s) <br /> LL FacflgsPhone: <br /> W 16C Sgnalure MAllemate FabNly le Genemlol <br /> 4 this 96rowilo oir is shipr3ili4 MnnM Day Year <br /> 2 <br /> w <br /> 19 Hazardous Wase Report Manager rut"chme:Comes 0 e.renes V hazernus waste tm merit.disposal.Who recycling systems) <br /> IA- <br /> 211 Oasignaled Factity Owns o Operator CeefnajK M recmpl0f razardpae ftmmfR S co erect try the mantles except as noted in Item Isi <br /> Pnmad4ypetl Name_. II Signature / ._,.f.. i' kwm Y:I Tei}, <br /> EPA Form 570D22(Rev.3.05) PmyiDus edhws are obsolete. .31 <br /> n ( _ , DESIGNATED FACILITY TO GENERATOR <br />