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Please print or type. - Farm Approved. OMB No. 2050-003! <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Tracking Number <br /> WASTE MANIFEST kliA.y OOD288489 y 88&785-7225 2 2 8 3 4 113 FLE <br /> 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br /> Dragon ESP i_TD <br /> 15700 McKinley A%enue sherii. "hea®moclwnusa. com <br /> Lpp CA 933 <br /> Genhone: <br /> 9I 25 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> Adanced Cfiemical Transport Inc./DBA ACTEN`✓IR0 CAR:M070540 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> B. Designated Facility Name and Site Address U.S. EPA ID Number <br /> US Ecology Nevada, Ync <br /> PO Box 578 Fi vy 95, 11 Miles S Beatty <br /> Beam;, tiv 59003 <br /> Facility's Phone: 775.553- iW <br /> gra 9b. U.S. DOT DescdpBon (inducing Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> and Packing Group fan 13. Waste Codes <br /> HM 9 p G y)) No. Type Quantity Wt,/Vol. <br /> ' - `: "' lazardous waste, solid. n o.s. (Chinxmiti 9 , PUll OM p 081 DGO? <br /> o Y <br /> y, <br /> M ZNA3077, diazardoui waste, solid, in o. s. {CM0MAJM, 0M p COD7 0011 18i <br /> didSILb'ER) , 9 , PGW <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information Project NIUII 17714 DDcl.trnent 0213D38 <br /> 1 ) ERG#77y ; 0701239L1g, 13302 Di2G - <br /> 2) ERGItd7d . 0T1283636£100 DRLJL_ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are diessifed, packaged, <br /> marked and laheled/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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statementldentified In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ifI am a small quantity generator) is true. <br /> Generator's/Offeror's Printedrryped Name Signature Month Day Year <br /> rr: <br /> 16. International Shipments <br /> F ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br /> - ? <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> w 17. Transporter Acknowledgment of Receipt of Materials <br /> Transporter I Pnntedl Name <br /> Month Day Year <br /> aZ Transporter 2 Printedrryped Name Sgnature Month Day Year <br /> K <br /> 10. Discrepancy ., <br /> 1 Ba. Discrepancy Indication Space ❑ Quantity ❑ TypeResidue ❑ Partial Rection je ❑ Full Rejection <br /> Manifest Reference Number. <br /> F 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> zi <br /> U <br /> I Facility's Phone: <br /> w 18c. Signature ofAlmmate Facility (or Generator) Month Day Year <br /> G <br /> z <br /> y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 . 2. <br /> 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printeallyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COP' <br />