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Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.1 nerganq Resp=e Phone 4.h6f1 Mpg{lur e 0 <br /> WASTE MANIFEST r - f Ju -, -JO FLE <br /> 5.GeneralAfs Narne and Mailing Address Generator's Site Address(if different than mailing address) <br /> Dragon ESP LTD <br /> 15Ill!!gl In1w Avenue <br /> WhraGA 95330 <br /> GaneraWs Crone: 2M�L�l 75 <br /> 8.Ta rlspoder 1 Company Name U.S.EPA ID Number <br /> M aced Chmnicai Transport Inc./DBA ACTefriro CAR000070540 <br /> 7,Transpoder 2 Company Name U.S.EPA ID Number <br /> 8:Dnsi riated Facility Name and Site Address U.S.EPA ID Numbar <br /> US i r(A t4eiz&, Inc <br /> 1-1a Box h1$ 1%'1 1 Mlles 's boatty IVVT'330t11U'(1i)f! <br /> Beatty, NU 3 <br /> Faditly's Phone: 776.563-2243 <br /> ga, 91b.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.NA1993,Ccmhusdble liquid,,n.o,s; ([isvxl lNesel),Comb By, C>r1A j P i <br /> k PGIH <br /> W <br /> W 2. <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information F�"act Nwrit" 2W%7l mIN11ant#'D322H'7y <br /> 1)ERG0 2 ; 070131570}24136 DRLII....4' I ^ Y <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 classified,packaged, <br /> marked and labeled/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 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'slOfferor"sPrintedlTyped Name Signature Monlh .,�Ial Yeai <br /> 1 X' r= <br /> J 15.Internstfonal Shipments <br /> H ❑trom I,U.S. ❑F�Port from Us. Part of enlrylexit <br /> z Transporter signature(for exports only). Data leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Transporter 1 PrrnlstllTypad Name Signature Mon(h Day Year <br /> O <br /> aTransporter 2 Prfntedrrylaad Name &gnalure Month Day Year <br /> aH <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ QuantityL1T e <br /> YP ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Referemz Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> C3 18t.Signature of Allemate Faclliiy(or Generator) Month Day Year <br /> Q <br /> Z <br /> 7) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 2. 3. 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnbedriypad Name Slgnoture Month Day 'a' <br /> EPA Form 8700-22(Rev.12-17) Prevlaus.editions are obsolete. GENERATOR'S INITIAL COPY <br />