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Please-print or type. Form Approved. OMB No. 2050-00 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number - 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number - <br /> WASTE MANIFEST C-ALO00286469 1 w&785-7225 1 012283412 FLE <br /> 5. Generator's Name and Mailing Address P'';. r ._,4r,4 Generator's SiteAddress (if different than mailing address) <br /> Dragon ESP LTO <br /> 15700 McKinley A .enue sherri. hethea@modernusa. com <br /> - Lathrop, CA 95330 <br /> Generator's Phone: 125 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> Advanced Chemical Transport InaJDBA ACTENVIRC CAR000070540 <br /> 7. Transporter Company Name U.S. EPA ID Number - <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> Adiianced Chemical Treatment <br /> 6133 Edith BW NE NMD002208527 <br /> Albuquerque, NM 57107 <br /> Facility's Phone: 505-349-5220 <br /> ga go. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Thal 12. Unit <br /> HM and Packing Group (if any)) No, Type Quantity Wt.Nol. 13. Waste Codes <br /> 1311 UN1325, Waste Flammable solids, organic, rUl IX� P 00D1 r Fa <br /> 0 x (ACETONE, METHANOL), 4. 1 , PGIIGp F003i F005I 35 <br /> w <br /> Z 2. <br /> w <br /> t7 <br /> 3. <br /> 4. <br /> 14. special Handling Instructions and Additional Information Prnlect Number 177942 Document # 0213037 <br /> 1 ) ERG#133; ACT32'220 0pl OQ .0 0 <br /> 15. GENFR TOWSIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consignment are fully andaccurately 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 natlonal 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 /> Icertify that the waste minimization statement identified in 40 CFR 26227(a) (it I am a large quantity generator) or (b) ('ri a small quantity generator) is he. <br /> Generator's/Offeror's Pnnted/Typed Name Signature _ - _ Month Day - Year <br /> 16. International Shipments <br /> r- ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit. <br /> ? Transporter signature (for exports only). Date leaving U.S.. <br /> as 17. Transporter Acknowledgment of Receipt of Materials �. <br /> H- Transporter 1 Printed ypetl Name Si nature <br /> r g Month Day Year <br /> az Transporter 2 Printed/Typed Narmi Signature f Month Day Year <br /> K <br /> t- <br /> } 18 Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18h. Alternate Facility (or Genemtor) U,S. EPA ID Number <br /> v <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Yea <br /> Q <br /> Z <br /> y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, antl recycling systems) <br /> p 1 . 2. 3. 4. <br /> /.! ! zr _ <br /> 20. Designated Facility Owner or;Operator+ Certification of receipt of hazardous materials covered by the manifest except as noted in lte _ <br /> Printed/Typed Name Signature Y / Month Day Ye <br /> r , <br /> EPA Form <br /> -22 are obsolete. ESIGRATEDFACILITY TOGENE C <br />