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Please print or type. Form Approved.OMB N - ERATOR 1.- I UNIFORM HAZARDOUS WASTE MANIFEST 1 . Generator ID Number CAD980.8144300 2. Page 1 of 1 3. Emergency Response Phone 898-785-7225 .. 4. Manifest Trackkg Number 016 5 0 4 2 0 9 FLE Generators Name and Mailing Address Generators Site Address (if different than mailing address) JR Simplot Co. 16777 HoiMand Rd. Lathrop, CA 95330 Generators Pone: 909.30-1_707e. r Transporter 1 Company Name U.S. EPA ID Number Advanced Chemical Transport Inc./DBA ACTenviro I CAR000070540 Transporter 2 Company Name U.S. EPA ID Number I Designated Facility Name and Site Address U.S. EPA ID Number Waste Management - Kettleman Hills 35251 Old Skyline Rd CAT000646117 Kettlernan City, CA 93239 Facility's Phone 5 Im..: 386_9711 I ga. 9b. U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt.A/ol. 13. Waste Codes lNon-RCRA Hazardous Waste Solid (Pond spill clean up)oo Oda DM 3c P 181 ... _ ... . ...._ . z w 2- Wall" VC i-Pr- 41)-Z4{Loovs w(vsit .5a46(1111).120 sf la WO) Dp j 14. Special Handling Instructions and Additional Information Project Number 374287 Document #: D454133 1) CA621915 JRW- b2c 55A or&I'l 2-)64-6.211/Sjitvu-18),s______ J__...!=.'___T -Cif 15. 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, and are classified, packaged, 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 Exporter. I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) lift am a small quantity generator) is true. Generators/0 rors Printed/Typed Name ja cf Signature i." ...._,__--- Month Day Year X 7 &-al" de ,- I 67 1 2 --1 _, r-- 16. International Shipments Import to U.S. Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year CA4400144401/fl'i) I G4". 4 - I 47---10- I z-- Transporter 2 Printed/Typed ame Signature Month Day Year I I I I 4-- DESIGNATED FACILITY --0. 18. Discrepancy Discrepancy Indication Space Quantity LI Type Residue Partial Rejection Full Rejection Manifest Reference Number: Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I Signature of AJtemate Facility (or Generator) Month Day Year I I 19. Hazardous 1•Vaste Report Management Method Codes (i.e.. cedes for hazardous waste treatment, disposal, and recycling systems) 1 2. 1A1(3r------ 3. 4. 20. Designated Facility Owner or Operator Certifica snot receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typedpve f-tinf)(10„__R. CU verv 1 Signature c.)\-R.c.„----____. Month Pay.- Y_ear 109 1 'd•I A EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete.