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7 t �' <br /> A a <br /> e� <br /> G FormAppreved, OMB No. 20500039 <br /> j QUS <br /> I. Denataimr lDNumbar 2. Paget of 3. EmegancyMaepons Mae 4. Manna.lown Nu r <br /> euu4 FEBT CAL000286288 1 209 S49 aS42 0 0 2 9 7 5 4 GBF <br /> ' .'Elpimieark(a Name ae moping Address. . . 13anaratore SiteAdaess Upddferenl pan moping address) <br /> H&M MARKET SWN98 <br /> 531 MCHENRYAVE 2601 E. JACKSON <br /> MODESTO, CA 95354 ESCALON, CA 95320 <br /> ' ieenawofePhon39M4&5612-105 <br /> B. immsporter l Company Name U.S. EPAID Number <br /> AMERICAN VALLEY WASTE OIL, INC. OAR000272302 <br /> Ir Trensporter2 Company Name US. EPAID Number <br /> h STERICYCLE SPECIALTY WASTE SOLUTIONS, INC MNSGOOI10924 <br /> B. Deatgnaled FadgryNemeentl She Address <br /> CORDON , LLC. U,S. EPAIDNumher <br /> 11855 WHITE ROCK RD, CAD980884183 <br /> RANCHO CORDOVA, CA 95742 <br /> Fep aPbone06-351-0980 <br /> gy wUS.DOT SestdOatlan (Ndtaft PrgrerSNpping Name, Hand Gars, I I Number, ie. Conalure <br /> HM' end PecM11.ToWt 12, Unit 13. Waste Codes <br /> ngOroup (geny)) No. Type Quangly WILWO <br /> X t RQ, UN4268, WASTE PETROLEUM DISTILLATES, N.O.S., 3, PGII, 1 DM 55 O D001 0018 331 <br /> GASOLINE, DIESEL <br /> u�7 2, <br /> co <br /> 3: <br /> 4. <br /> 4. 6 at Ha OlnglnsaudionsandAddlOonalinfondon <br /> PROPILE#790731-02 WATER & GAS ERGM126 <br /> EMERGENCY CONTACT, MONICA <br /> IS. OENERATOR'SIOFPEROR'$ CERTIFICATION: i hereby dentes I.W thews onto ofNs consignment arelully aM eaua" desaihed abovaby the premrshiWirg nems, ab are deseiRed, peelseged, <br /> medud and lebeliroacedad, wolaie In all map" In proporcopollon kr in Asportaccooling loappllwblelntematlonNegd Impanel governmental regulations. IfexponahlpmeNand lam On Primary <br /> F.rpod (Mtthey telhin(mbAn6 staimensideng con4OCFR 2x ,27(o) mashed EP ntlyga Aedgsoor(b P(Iam <br /> IwNfylhal lhevmsle minlm6aggrtaml?mentdenggetl ln40 CFR28227(a) lemalage quantlygetrerela)err@) @lemeemal quangty genaato41slnw, <br /> GersreWda'Ofleroya Pdnt Td acrd Name ignalure nM Day Year <br /> F to <br /> 19. 1neindor lShipments ❑(mpadto U.S. ❑ Export Aran U.S, Pat ofemrylexit <br /> TansporteralgnaWrq (for e[port6ony): Data leaving U.S.: <br /> 77.TmnwpakrA*n_*edgmenlof ptofqwws <br /> araporwre <br /> 1. q. - Month Day yjair <br /> d <br /> eQ Tans yP erne Sgnalure N Day <br /> Ucrr I I r <br /> 18. DNaepvwy ' <br /> 18a. Discraimry lndlcagon Space ❑ Qmangty E Type ❑Resdue . <br /> ❑ Pedal Rejection ❑Fug ReJwtlan <br /> M estReramnce Number. <br /> 18b;A11ertalb Fadl'4y (orOenRator) . - - U.S.EPA ID Number <br /> Fe_ctlftys Phone: <br /> Signeldre 01AMMI )Ha (urGeneaW Month 'DW' ear ' <br /> ° r <br /> rr <br /> , dp4a . ,pe Rsjwit MemjgBnlOnYMegiodOodeg (la., wdesbr wasWtraalrcsnL disposal antlre5ydmsyeleme) <br /> 2. 3. 4 <br /> �,ne[a{iPaa'GlyOdnB.rorOpaaton CeNgatlpnofrewipldherardowma ' covered by the as noted in Jim mea <br /> r p $ignelure IF Day <br /> RR8700$2 (Rev 12-Yn Pre oes Wilma ate obsdole. DESIGKOOD FACILITY TO ERA's a MAlIIFEBT 9 <br /> w : ; + <br />