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corm da ted for use on eze{"2-le vrlter.) <br /> ,tAZARDOUS 1•C+enaralx ID 2 Form Approved.OMB No,Z-..5�-Xx <br /> lea 1 of 3.Es =sur�aart.' 4 Manifest Traddrig Number <br /> ...w '�"t 004907913 J, K <br /> ards Name and MaiAngAddress Grp , .,�. address) <br /> '-- J R SIMPLOT <br /> „r 16777 HOVA AND ROAD <br /> i LATHROP,CA 95330 <br /> ' Gonerator's Phone: <br /> 6,Transporter 1 Company afire969 2U.S.EPA tD Number <br /> EVERGREEN EWR0hWl=-t 'AL S_=liICES CR�82413252 4 <br /> 7.Transporter 2 Company Marne US.EPA ID Number <br /> 6.Designated F-acRy name ark S Ar U S.EPA ID Number <br /> EVERGREEN OIL.INC. <br /> SM SMITH AVE. CA09MM7418 <br /> NEWARK,CA 9d5�r <br /> F Phone: 510.735-4" <br /> 9a. 8b.US.DOT D--M or.f Pic s*ft Name.Hmm Class.rD Number, <br /> HM and P20ft C-.ar fd aa;.9) �r °� 14.Tow 72 Urdt <br /> Type WLNd 13.Waste Codes <br /> IV G/W.3� too f f:�03 <br /> 7-1 <br /> 3. <br /> Y y <br /> 4. <br /> q00 <br /> 14,Specialt Add6Dn8l fnfamra5orr '��� _ <br /> profilel�iJ a � dntm s1ze.A. <br /> 15. GENERATOR=FFERMS CERMCA7MN:—1hereby dedare that the=aan of Ltis conslgrsnent are f and eragatety above by Bre proper pP�g name,and are dasstRed,Imo, <br /> marked and rpl nft,and gra In ail respects In pMM cnn r&n far tanspo i � to nim able h and <br /> omni end dasalal <br /> F�orter,I�that Bra oorrtoras of fids om=V ne d aadoim to the terms of ftaqoi <br /> a fired E AAda plica gnesrrt d Carrsent If expel shlprrrertl and 1 am dre <br /> I aertffy Brat Bre waste mhr rrhation statement fQe&hd in 40 CFR 262.47(a)tB I am a targe 4u0rddy generator)or(b)(rT I am a we Warr5ly generator)is baa. <br /> GerterafafsrOSero>s Nasne Stnehee hftM Day Year <br /> J 1ti.lnterrr�tiar>al <br /> z ❑tmporl to us. ❑Export from U.S. Por103 entryjardkt <br /> Trarmlo'erV-t-e(for-p-is°M# DateIua US.: <br /> 17.TMMMter of Rw*0f MJab3rMs <br /> Trerrsportar 1 Name Signature Month Day Year <br /> aTnanr 2 NameSealure M orm my Year <br /> M.D&mpm y <br /> 18a.OisuspancyInflation Spm ❑ ❑Type <br /> ❑Re�due ❑PW R*,tlon ❑Full <br /> i8b.AttBmate f {�Genpte4m) MMBast Rafervve Nrmiber: <br /> U.S.EPA ID Number <br /> V <br /> Fe MYB Phone: <br /> Q1 Bc.Sfgnaturg of AtlemateFadrity m Gerteratcr) <br /> Month Day Year <br /> x <br /> ca19.Hamrdotm Waste Report Management MuaW Q*S M..cedes forhaurdous waste treatnenl,disposal,and recyrtmg systems) <br /> � 1. 2. 3. 4. <br /> 20.(a*wted FadGty Ovmer 0r Operator.Carffica6on of receipt of hazardous=tuft covarad by Bre mardiesl <br /> except as rated in tiara I& <br /> Prtrbayped Name <br /> - Month tlay Year <br /> EPA Form 870x22(Rev.M5) Previous ed;t m are obsoleta. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />