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Please print or Form designed for use on elite, 12 Etch ! <br /> P ( )ty'fifor. Form Approved.OMB No.20500039 i <br /> UNIFORM HAZARDOUS 1•Ganerator fD Number 2•Page 1 of 3.Emergency Response Phone 4,Manlfeet Tracking number <br /> WASTE MANIFEST CAD9=1.= s�7&10�s 1007412160 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than malting address) . <br /> ! J R Simplot Ctkf>tpatf]]ff . <br /> IBM Howland Road.. <br /> Lathrop,CA 9533(3 USA <br /> Generator's Phone: 26 -EKF <br /> S.Transporter.1 Company Rame U.S.EPA ID Number <br /> DILLARD''ENVIRONMENtAL.SERVICES CAD%2523433 <br /> 7.Transporter 2 Company Name U.S..EPA ID Number 4. <br /> 8• U.S.EPA ID Number <br /> 11600.Nodh.Apttls Rd UTD981SM177 <br /> Aragontte,UT 84049 USA <br /> Fadlilys Phone: 801.3436100 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pacidng Group(d any)) 13,Wasta Codes <br /> No. Type' Quantity WWol. <br /> a X 1• UN1090,WASTE ACi170NE,3,PG H . 1 DM P CMI 1003 331 <br /> ;0 <br /> ;.� <br /> 166 . <br /> ;zX:,2, . Ute,.WASTE MERCURY;COWAINED:IN,MANUFACTURED 1:.: > .. l; P 170p9 141.. 725 <br /> ARTICLES,B„PGJII J <br /> I <br /> i <br /> 3 i <br /> f <br /> i <br /> I <br /> 4. I, <br /> Ii <br /> .14 Special HaotlliiigInstructions and Additlonal information {, <br /> 1: 1, �. gq 25g i <br /> 28) <br /> r E. <br /> 15. GENERATOR'&IOFFEROR'S CERTIFICATION::I hereby declare that to conlenfs orthfs consignment am fully and accurately described above by iha proper shipping name,and are classified,packaged, <br /> marked A—IAtieletllplacarded,and are In aff respects In pMxroxidtdon for transport s000rd'Ing to appiicabfe Weinalionaland national govemmental regulations.If export shipment and I am the Primary <br /> ;Firpot rj l.crettlTy that the contents of this consignment corrbrn to the terms of the attachad EPAftnowledgment of Consent <br /> certifyr.'h Its waste minimtzation statement Identified In 40 CFR 262.27(a)(11 i am a large quantity generator)or(b)(ff l am a:small quantity generator)is he. <br /> Gen 77riritedlTyped Name Signature, Month Day Year e <br /> :r €16:'Inteniationaf 5liiprinenfs <br /> F= AA <br /> ❑Import tD U.S, ❑EoR from U.S. Pod or entryferdt <br /> :�T"porrer:si9nA e,(for_ezports only): Date leayr�U.S.: <br /> af <br /> W:'t>.Tr�^spo%+ irk s <br /> a' Tnatisparter'�:PiiniedflyW Name.' Signature Month Day Year <br /> �? 19 9 <br /> Y - rinfedflyped Name re Month Day Year <br /> 18.Disc*c, <br /> 18a,Disaapaniy Indication Space ❑ Quan <br /> bti' ❑Type �Residue ❑Partial Rejection 0 Fufl Rejection , <br /> i <br /> I <br /> Manifest Reference Number: <br /> 18b.Atemate Fadlity(or Generetor) U.S.EPA ID Number <br /> Wil. s <br /> L Faclu y's Phone:. <br /> U0 18d Signature of Atemate Facility(or Generator) Month Day Year I <br /> ! <br /> 55 19.Hazardous waste Report Management Method Codes 0.e.,codes for hazardous waste treatment,disposal,and reeyclmg systems) <br /> --7 <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.Cerlifrcatkm of receipt of hazardous materials covered by the manlfad except as noted in Item 18a <br /> Printedrryped Name Sig fore Month Day .Yeas <br /> .PA Form 870D-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />