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Please print or type. Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. GeneratorlD Number 2. Page 1 of 3. Emergency Response Phone 4, Manifest Traccking Number <br /> WASTE MANIFEST CAL0002BB489 1 1 .8W7�722rj 012 6. V .e L r m� F LE <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> Dragon ESP LTD <br /> 15700 McKinleeyy Aeenue sherri . hedile�modernic:orn <br /> rati`:rop, CA 3a0 <br /> Generator's Phone: 209-688.9125 <br /> 6. Transporter 1 Company Name U.S.:EPA ID Number <br /> tl.cWnced Chsmicai Transport incJDBA ACTENVIRO CAR000070r,40 <br /> 7. Transporter Company Name U.S. EPA ID Number <br /> 8. Designated FacilityName <br /> I\Name and Site Address U.S. EPA ID Number <br /> US Banc cd ag57895. Inc <br /> 11 Miles S Beatty <br /> PO BPE irr "JIZIM 0000 <br /> � �-�y <br /> Beatty. NV 89003 <br /> Facility's Phone: 775^5532203 <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containam 11 . Total 12. Unit <br /> HM and Packing Group (if any)) 13. Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> did NA3077, Hazardous waste, solid, n o,s. (CHROMIUM, DM p OW7 D041 181 <br /> 0 SILVER). 9 , PGIII J ( 0 <br /> z 2. <br /> w <br /> (7 <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional Information PI mritter 171L.01 a.nhu nG rt It ii-D2015936 <br /> 1 ) ERGIt171 : 0701289038900 DRLL <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the 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 intemat'onaland 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimisation statement identified 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/OfferoPs Printec/Typed Name Signature Month Day Year <br /> i . <br /> 16. International Shipments - <br /> i- ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit <br /> ? I Transporter Signature (for exports only): Date leaving U.S.: <br /> W 17. Transporter Acknowledgment of Receipt of Materials <br /> Tran. <br /> ponar 1 Printed/T p ed Name <br /> O YP Signature�� Y, - - Month Day Year <br /> CIL - _ - �� < _. . _ . '... � t <br /> z Transporter Pnntedfryped Name Signature Month Day Year <br /> ag <br /> r <br /> 18. Discrepancy <br /> 16a. Discrepancy Indication Space <br /> ❑ Quantity El Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number, <br /> F 70b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> z <br /> w19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 3. 4. <br /> 1 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 10a <br /> Pnntedgyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editlons are obsolete. GENERATOR'S INITIAL COPY <br />