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Please print or type.(Form designed for use on elite(12-0tch)typewnter.) r', p 5('(`-k' Form Approved.OMB No.2050.0039 <br /> 1.Generator ID Number "' 2.Page 1 of 3.Emergency Response Phorm 4.Manifest TrackingNumber <br /> WASTE MANIFEST <br /> UNIFORM HAZARDOUS CAL000279478 1 209-4W1477 0023 6 3259 G B F <br /> 5.Generator's Name and Mailing Address J H SIMPSON CO Generators SileAddress(if different than mailing address) <br /> 4025 CORONADO AVE <br /> STOCKTON.CA 95204 <br /> Gene2lor's Phone:209-466-1477 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> AMERICAN VALLEY WASTE OlL,INC. GAL000827878 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 21 . �� 1 uTllh 1 q1 �Gh(x I 9 f L CAr�b(WJL/C17 <br /> 8.Designated Facility Name and She AddressU.S.EPA ID Number <br /> 21ST CENTURY NMENTAI MQM F NEVAOA,LLC NVD980895338 <br /> 2088 NEWLANDS DR.OR.EAST <br /> FERNLEY,NV 89408 <br /> 775.575.27eD <br /> Facililya5 Phone: <br /> ga 9b.U.S DOTDesaiption IarJd'ng Proper SNpping Nene,Hataid Cease.ID Number, to.Crdairars 11.Total 12.Unit <br /> N14 and Packing Group( "I] No. Type Ourdity, "AU 13.Waste CDdes <br /> I. W082 WARDWS WASTE,LIGs(1lD,N.O.S.9 POIII ,e�, DM .BBI G F001 223 <br /> 0 ' (RF-FRIDGERATOMI OIL WITH TRACES OF FREON) <br /> z 2 <br /> w <br /> c� <br /> i <br /> N.Special Handing Instructions and Addilkrel Information <br /> PROFILE 040234-00-REFER OIL WITH TRACES OF FREON <br /> ERQT "i <br /> EMERGENY CONTACT•ROBERT <br /> 15. GENERATOR'SIOFFERORSCERTIFICATN)N' I teombidedxe that the contents aleis consignnxr,(are lullyand arslraldydascrpedabaye ay IN pm(rsnippng name.Wd am dasmfod.packaged. <br /> marked and labolalrpHwrded and aro in all aspects M pmllwcondlun to Pansped moponling to air6cable InlemaNpialand retlonal govemmarsal regulations.I export shlpmmrt and I am Nie Naef <br /> Exporter,I uealy dal die comenu of Oils onsgrnenl conformlo The lerm s of In aaached EPA AckruAledgmenl of Ccmam. <br /> I ceMy Ihat Ufa waste midmfzeaon slaumzw idemded m W LFR 28217(a](d I em a Inge quana[y gsns�atrlar IC)(41 am a amort quantity genarauq Is We. <br /> GeneraWwOffenas PneseMyped Name Sgnware 1 / Month Day Year <br /> 16 International Shipments <br /> ❑Import to U S. EjExpw an U.S. Ponotero'yres <br /> TaespoRa s nalu a Ilor ewes ontyl Date lea+ing U.S.: <br /> 4' I1.Trxipcner Apanow"imen W Receipt of Mdlerios <br /> Tramped1P y*Nrne SgnMum Month Day Yew <br /> S r, Ke k/ 171)1111 <br /> Translill2 Riypadry�n» (( s' Mon t <br /> tIS DdGMprty . <br /> 18a.Discrepancy Indiction Spores ❑ Quantity ❑Type ❑RM" ❑Partial Rejepgn - ❑Full Rejection <br /> ileal Reference Number. <br /> tab.Alamos Faolity,(a Generalorl U.S.EPA ID Number <br /> has the aWofNIOCe p]erinni <br /> LL Fadilys PArie. <br /> lec'YglMure dAOemale FaaldYfor GeneglorJ hbMn Oay Yea <br /> ithis gbnemitim i5 shlplfll% <br /> y19.Hazwdoua Wasu Report Management Method Cockle,(l a.,[oda for heaadaa wale Im~,dspos9,and mcydirg systems) <br /> C <br /> 20 DtKnisled Fa.Ry O-w�ner,',orr oppwjaloe.cneAoamn at rexnpl o/f�hyazarooua malwids eorrad by the menires exceptas nYea n Ium 16a <br /> nrneMyped Nam...�✓'e (fL///r bar <br /> EPAFbrm8700-22(Rev.3.05) Previous editions are obsolete. <br /> 0 3-10--1 4 P 12 :5 7 R C V L) DESIGNATED FACILITYTO GENERATOR <br />