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Please pent or t Fom*esigned for use on elite (12-pitch) lypewnter.) Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 , Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tk ng Number <br /> WASTE MANIFEST CALD�648r� i 1 •:- ` . :3-i' FLE <br /> 5. Generator's Name and Mailing Address Gene2tor's Site Address (it different than mailing address) s <br /> Dragord ESP LTL1 <br /> 157M WKWAN AAul sham. hethas®m0dmwsmoull <br /> Lai UA Wl <br /> Generator's Phone: -12S <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> Ad'ren_e,1 ChairnioN Trwspat kr../DBA ACTEWAID <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8. Designated FaName and Site Adtlress U.S. EPA ID Number <br /> cility <br /> PO E30x 51,1,f�+�iry s95, •t 't 11 ids S Lleatty NM&P31 ,k'1Q1T <br /> Remi N , 8®OD3 <br /> Facility's Phone: 7 75m653%?20;3 <br /> 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 19. Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) <br /> No. Type Quantity Wt.Nol. <br /> o X X51 r . Hvaardoris 1Vaste Sobds N.O.S. (Ba[imn) , Q PGffi �c ^� , r ❑ODS f 181 <br /> OC �ro <br /> w WA3077. Has=rdnrr - waste. fid, n.o.& (CHROMM, 7'"17 D011 ` 181 <br /> X SILVER), 9 , PGZ W -7 F.� i <br /> 3 ✓ <br /> 4. <br /> 14. Special Handling Instructions and Additional Informationoded Nidrnber 151577 Wolin; sl i <br /> 1) 070128301-15179 DR4ltiT c <br /> 2) ERGN171; 0701283036900C a - <br /> 15. GENERATOR'510FFEROR'SCERTIFICATION:- I-hereby declare that the contents-of this consignment arefully.and accurately described above by the proper shipping name, and.are class!ied, 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 EPAAcknowledgment of Consent. <br /> I certify that the waste mlMmlzadon statement idenOAed in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. <br /> Generators/Offerore Printedfryped Name Igna ure - ont ay ear <br /> '-7d , <br /> -__ — f <br /> 16. International Shipments <br /> 2 l❑ Import to U 5. ❑ Export from U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> of 17. Transporter Acknowledgment of Receipt of Materials / <br /> Transporter l PrintedlTyped Name Signature _ — on ay ear <br /> a Trans orb Printed/ipe I y - 0 •• I t Da I ( <br /> R ✓ <br /> d Name Signature �' - - Month Day Year <br /> H <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ ❑ Partial Rejection <br /> ❑ Type Residue ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA 10 Numberzi <br /> Q <br /> LL Facillb 's Phone: <br /> w 18c. Signature ofAltemate Facility (or Generator) <br /> F Month Day Year <br /> Q <br /> z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> w 1 2 <br /> 0 3. 4: <br /> ` � <br /> 20. Designated Facility Owner or Operator: Cahification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed,'Typed Name Sig ature %. / Month Day Year <br /> Odd <br /> EPA Form 8700-22'(Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />