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Please print or type. Y 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 I CAL7002W489 & 785-7225 1 012283675 FL'E <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> Dim <br /> gon ESP LTD <br /> 15700 McKinley AWnue Sherri. hethea@nTodernusacom <br /> Lathrop, CA 95330 <br /> Generator's Phone: 9125 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> Adtrdnced Chemical Transport Inc./DBA ACTENVIRO CAR000070540 <br /> 7. Tmnsporter2 Company Name U.S. EPA ID Number <br /> �� r7 = 1 / ( r +2 � r✓ iti _ P t7 � C. r c ain010 -107 <br /> U. Designated Facility Name and Site Address U.S. EPA ID Number ' <br /> Adiianced Chemical Treatment <br /> (3133 Edith Bbd NE NMD00220866247 <br /> 4lbuquerque, 349-SMO <br /> M 87107 <br /> Facility's Phone: <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.Nol. <br /> 1 LTN1325, Waste Flammable Solids, organic, n.os. <br /> o X (ACETONE, .WETHANGL), 4. .1 , PG5 DFA P OD01 DD35 F00; <br /> `, 1 FC03 FCO6 362 <br /> Z z. <br /> W <br /> 3. <br /> I <br /> 4. <br /> 14. Special Handling Instructions andAddidonal Information ect � � 1 DOCUrfir3Y'it # D219t3 <br /> 1 ) ERGYl133; ACi32220 DRA- C�`: t _• C�„���Z Y � �f <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelyrdescribed 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 internationaland national governmental regulations. If export shipment and I am the Primary <br /> Extoller, 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)-(if l am a large quantity generator) or (b) (IfI am a small quantity generator) is true. - - <br /> Generator'slOfferors Priptedrryped Name Signature Month Day Year <br /> . r <br /> 1:1 Import to of <br /> � US 16. International' Shipmenh - <br /> ❑ Export from U S Port of try/exit <br /> Z Transporter signature (for exports only) p Date leaving U.S.: <br /> w 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrrypetl Name Signature k Month Da Year <br /> - Y <br /> ansportAr2 Printed yped Name 0ay / <br /> Signature Month Day Year <br /> i N � V / e J /3 ) / 26 <br /> __ ♦ 16. Discrepancy - _. - _ -. - - <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ <br /> Type E] Residue ❑ Partial Rejection ❑ Full Rejection <br /> F 18b. Alternate Facility (or Generator) Man'rfest Reference Number: <br /> Zi U.S. EPA ID Number <br /> U <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) <br /> R Month Day Year <br /> Z <br /> U5 79. Hazartlous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) - <br /> 1 <br /> /fix z' 3, 4' _ <br /> 26. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifes except as noted in Item 18a <br /> Pnnted/Typed Name _ Signatu Month Day Year <br /> EPAFo m 8700-22 (Rev. 12:17) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />