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Please print or type. Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST . CALO00286489 1 66a7t39L7225 012283677 FLE <br /> 5, Generator's Name and Mailing Address Generator's Site Address it diflerent1han mailing address) <br /> Dragon ESP LTD <br /> 15700 McKinley A1,enue shed. hethea@modemusa. corn <br /> athrop� CA 963'30 <br /> Generator's gone: 209, D <br /> 6. Transporter 1 company Namaell: U.S. EPA ID Number <br /> Advanced Chemical Transport Inc./DBA ACTENVIRO CAR00O070W <br /> 7. Transporter Company Name U.S. EPA ID <br /> Woridvvlde Recovery . . Number <br /> System, Inc CAR0O0175422 <br /> b <br /> __ - UI EPA 0 Numer ...... —. - . <br /> Yuma YES, LLC - <br /> 2730 E. 13th St A2RO00515924 <br /> Yuma, AZ 85365 <br /> Paciliry's Phone: 928344-9828 <br /> ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) 13. Waste Codes <br /> No. Type Quantity Wt./Vol. <br /> W 1 Non-RCRA Hazardous Waste Liquid (Oil, Watil <br /> lbbbb� OM �q IZ P 223 <br /> w <br /> 3. <br /> 4. - I <br /> 14. Special Handling Instructions and Additional InfonnaGon / Document f'$ D219665 ` <br /> 1 ) 181102 GRY ��( 5 � <br /> trey 18312D <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that he contents of this consignment are fully and accurately described above by the proper shipping name, and 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 expel 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 minimization statement identified 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 /> GeneratorslOfferor's Printed/Typed Name i signature I Month Day Year <br /> ,� 16. International Shipments IIr cr, I 17f <br /> LJ import to U.S. ❑ Export from Part of enlrylexit <br /> bbbb, Transportersignature (for exports only): Date leaving U.S.: <br /> M 17. Transporter Acknowledgment of Receipt of Materials <br /> Lot <br /> Transporter 1 PnntedlTyped Name / � Signature Mo Day Year <br /> p , r'1 `P._ r i <br /> R ped Name "Signa be Month Day Ye <br /> 18. Discrepancy <br /> 18a. Discrep cy Indication Space 'r-� <br /> / ❑ Quantity ❑ Type LJ Resitlue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> F 18b. Alternate raptly (or Generator) U.S. EPA ID Number <br /> J <br /> U <br /> <+ Facility's Phone: <br /> w . Ida SignatureofAlfernate Facility bur Generator) - - - Month Day Year <br /> Z <br /> y 19. Hazardous <br /> /vWaste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . . 1 i 2. 3 <br /> 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in I 18�/ <br /> 'Print R ed Name Signature Month Day Year <br /> Q- �- <br /> EPAForm 7Do-22 (Rev. 12-17) reviouseditionsareosOlete. ESIGNATEDFACILITYTOGENERATOR <br />