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Please print or type. Form Approved. OMB NO. 2050-0039 4 - - - GENERATOR UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAD980814800 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />888-785-7225 <br />4. Manifest Tracking Number <br />014709973 FL E <br />Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br />JR Simplot Co. .r. <br />16777 Howland Rd. •,:. Ilri V; <br />Lathrop, CA 95330 '.ti:. f . .. <br />Generator's Phone: 2uu_dots_b470 i - <br />Transporter 1 Company Name U.S. EPA ID Number <br />Advanced Chemical Transport Inc./DBA ACTenviro <br />I <br />CAR000070540 <br />Transporter 2 Company Name U.S. EPA ID Number <br />I <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />US Ecology Nemada, Inc <br />PO Box 578,Hwy 95,11 Miles S Beatty NVT330010000 <br />Beatty, NV 89003 <br />Facility's Phone: 775-553-2203 I <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />Ai and Packing Group (if any)) Na. Type Quantity ',/k/Vol. 13. Waste Codes <br />X <br />1UN1805, Waste Phosphoric acid solution, 8 , PGIII TP .--, op° P 792 D002 D007 <br />3 <br /> <br /> <br /> <br />14. Special Handling Instructions and Additional Information Project Number 281046 Document 11: 0341134 <br />1) ERG-#154; JRU- ExrP <br />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, aid are classified, packaged, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (ff I am a large quantity generator) or (b) di am a small quantity generator) is true. <br />GeneratortiOfferor's Printed/Typed Name Signatu Month Day Year <br />X Al V ftft. yrYttt 0, aer. r i'eyr.., itt41,(AtcLEA, 1 4,6_ Acs--) 1 1/--ia-1 <br />_,1 <br />i— F_ <br />16. International Shipments <br />Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date teasing U.S.: <br />04 Lll <br />17. Transporter Acknowledgment of Receipt of Materials TRANSPORT! Signature Month Day Year Transport Print Typed Name <br /> . ocl 1 '—i i 6( 6 4a_ <br />7 <br />Transporter 2 Printed/Typed Name Sgna:ure Month Day Year <br />I I I I DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Incication Space Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) I Month Day Year <br />1 1 1 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />\ }r1V <br />2. 3 4. <br />20. Designa ed Facility Owner,or Operator: Certifi tie ceipt of hazardous materials covered by the manifest ^ nded in Item 1 a <br />Pri ed peari ' nature <br />. <br />t.',,,..,2 <br />-..) I 10 <br />EPA Form 700-22 (Rev. 12-177 Previous ed(tion6 are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM