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Plea^se'3Tint or type. Form Approved. OMB No. 2050-003 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone4. Manifest Tracking Number <br /> WASTE MANIFEST CALo0028sae9 1 88&7 FLE <br /> 5. Generator's Name and Mailing Address Generator's She Address (if different than mailing address) <br /> Dragon ESP LTD <br /> 15570(0p pMoloCnIll Avenue sherri. hethea@modernusa. com <br /> CA <br /> Generator'sfiirOne: X3',5 y <br /> 75 <br /> 5. Transporter 1 Company Name U.S. EPA ID Number <br /> Adwnced Chemical Transport Inc./DBA ACTENVIRO CAR000070540 <br /> 7. Tmnspor[er2 Company Name U.S. EPA ID Number <br /> 0. Designated Facility Name and Site Address U.S. EPA ID Number <br /> US Ecol Nexada Inc <br /> PO Banc 578, µm 9$; 11 Miles S Beatty NIM30010000 <br /> Beatty, NV <br /> Facility's Phone: 775-553-= <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 WLNOI. <br /> 1NA3077, Hazardous o waste, solid, n o.s. (Chromium), 9 , PGIII <br /> X CIA 181 0007� <br /> 11ol00 h <br /> z 2NA3077, Hazardous waste, solid, n.o.s. (CHROMIUM, 0007 D011 E 181 <br /> X SILVER), 9 , PGRI OM P <br /> 3. 7b6 <br /> 8 <br /> 4. <br /> 14. Special Handling Instructions and Additional Information Pra)ed Npnpeff 1771 Doangent # D213038 <br /> 1 ) ERG#171 ; 070128303-13302 DRU 0 I - Gv i� ( $)'5�5-OrmlI <br /> 2) ERG#171 ; 0701283038900 DRU- y ;SJT�gr <br /> consignor are fully and accurately described above by the propershipping name, and are classified, packaged, <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: Thereby declare that the contents of this <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according t0 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) (if I am a large quantity generator) or (b).if I am a small ouch rty generator) is true. <br /> Generator's/Offeror's Pnnted/Typed Name Signature - - - - Month Day Year <br /> 161ntemabonal Shipments <br /> Ellniport to U.S. Ll Export from U.S. Port of entry/exit: <br /> ZTransporter signature (for exports only): Date leaving U.S.: <br /> w <br /> 17. Transporter Acknowledgment Of Receipt of Materials <br /> I ldf sporter 1 Primed/ I ya ame Signature Month Day Year <br /> CIL <br /> Q Trensporter2 Printed/Typed Name Sigratu / Month Day Year <br /> F <br /> 10. Discrepancy <br /> 10a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Radial Rejection El Full Rejection <br /> > <br /> Manifest Reference Number. <br /> F 1 Bo Alternate Facility (or Generator) <br /> U.S. EPA ID Number <br /> V <br /> tai Facility's Phone: - - - <br /> w 1Be. Signature ofAltemate Facility (or Generator) Month Day Year <br /> Z <br /> N19. Hazardous Waste. Report Management Method Cotles (i.e., codas for hazardous waste treatment, disposal, and recycling systems) <br /> 20. Designated Facility Owner or Operator. nification of receipt of hazardous materials covered 6y the mond <br /> d/Ty a t exceptas noted in Item Ire <br /> on - SignaNre f �Er Day <br /> , Jell <br /> EPA ForM.5700-22 (Rev. 12-11) revious editions are obsolete. —' ' I �� t e <br /> DESIGNATED FACILITYTO GENERATOR <br />