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Please print or type. a GENERATOR o- I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CADq80814800 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />888-785-7275 <br />4. Manifest Tracking Number <br />016 5 0 419 9 FLE <br />Generator's Name and %failing Address Generator's Site Address (if different than mailing address) <br />JR Simplot Co. <br />16777 Howland Rd. <br />Lathrop,Ph G4 95330 Generator's . one: 909.303.7078 I <br />Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport Inc./DBA ACTemiro 1 CAR000070540 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address US. EPA ID Number <br />Waste Management - Kettleman Hills <br />35251 Old Skyline Rd CATO/30646117 <br />Kettleman Glt , GA 93Z39 <br />Facility's Phone: 386-9711 I <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />NM and Packing Group (if any)) No. Type Cu2ntity WI.Nol. 13. Waste Codes <br />1Non-RCRA Hazardous Waste Solid (Pond spill clean up) <br />33 DM (500 0 P <br />i 181 <br />1 <br />kit 0 ---9-C.C..0- o ftzm.00.., 4.4-c-NE., t LI ace: P <br /> <br /> <br />Special Handling Instructions and Additional Information Project Number 374197 Document #: 0453584 <br />1) CA621915 JRW- <br />2-) CftZitii j itw- 15 -ç 01-P' <br />GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, art are classified, packaged, <br />marked and labeled/placarded, and stein all respects in proper condition for transport according to applicable intemationaland national governments! regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to <br />I certify that the waste minimization tatement identified in 40 CF <br />Itached EPAAcknowledgment of Consent. <br />262.27(a) (if I a a large quantity generator) or (b ' - ,, 4: an ity generator) is true. <br /> <br />Mil Ili PrwalliOtil Generato fferor's Printed/Typed Na ture 411 Month Day Year <br />X' A/411/a44S49 - IIIVIAMari ' I6q I 2 4 2Z, __I <br />F— <br />F_ <br />International Shipmen <br />Import to U.S. •Export from U.S. Po!'f entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: _TRANSPORTER Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />I "- I Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I ) FACILITY. Discrepancy <br />18a. Discrepancy Indication Space Quantity Type Res:due Partial Rejection LI Full Rejection <br />Manifest Reference Number: <br />18b.Altemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: DESIGNATE[ 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />19 Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />V62_ 2 N tem_ 3 <br />20 Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Mont, Yea .. 01/41Ylon& (< . Ceive,n v iZr.- - lot ii 1 <br />1 <br />orm -(I-fey. revtous edItions are obsolete. EPA's e-MANIFEST SYSTEM