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3927 E. Clark Drive PR0514138 <br /> June 26, 2018 <br /> PHOTO 55: Manifest 017791931 JJK from October 20, 2017 without a destination facility signed off copy. <br /> 'IM Farm dean nad for use an m-I-pltcN) wdler. <br /> U ORMNAZARDOUS 1.G-na IDNumbx 2Pageid 3E rgercy Response Nlwm ¢Man rtira.. "moi <br /> WASTE MANIFEST „.r .- i ttFxr R:M',R3IXf JJK <br /> scene a AA AAirees GeneralMa SibAddreee txedNreal uan mexmg eear.e.. -._._. __".._...__ � <br /> 8 hens re U 9 I�A <br /> l TrenapuM lCwrgenY N— US AID Numoar <br /> U.S.EPA IO Hwritr`+ <br /> e0i'q"41e0,F'�WNeIIR-aoys�eywaFp. <br /> ga 8e U5 Wt pesmpmn n'+audi+g Paper Snippny Name.Haxnrd Class 1p NumRei, 10.Co I. rs 11 T- 1}.UnR 13 whaled <br /> awP by4lwpfAenylt No. Type W—y W1Nd <br /> 1 <br /> U <br /> l <br /> 1e S—a H—rq mrmnon:a�aamnronal Idrom,asp� <br /> 15.GENERATOR'aIOFFEROR'SOERTIFI—ON:(hereby deGare Nal the wnlenl5 of thiswnsgnmenl are lolly and accurately tlescnbed above Uy Ne proper shipping ranw_a, ¢].pa.?ragcC <br /> mehed and lapNeNplxardM.a..'aa"I reepetnea'n," 'an,forI—daN a[arding N applirable'nlamalionaI and nahwlal governmental reg tali II �,.i. J z <br /> E.p -eddy Nat the mn4nbWlh's mne11renenl-1—b the terms of the laacletl EPAACM.adgment of Oonsent. <br /> mvry:Mleie wine mlrvnsvtnn—In denebad in 40 CFRM27(a)df em alargegoaably generelgyor(b)N I em a smell Waallry generator)Is We. <br /> CarrerafxLYMerys PnmaNtNam-•e� ---- _ SignAure i Month DaY, Vey - <br /> 16 Intenaaona'SNpmenN l I� r <br /> 2 ❑ImpM to US. ❑Expos from U.S. Purl of en I 1 <br /> i rrcgonn sgratnrelkr expdns only) Oate 1¢avnwg U.S.: _— _— <br /> w 17.harvspprlergtlrmexadgmenl olRmtipl of Matehels <br /> Trenpxtd 1 PHn—ypad Name <br /> i �..� <br /> QTramporlNlPrmlgd/{yyd Name <br /> Signature Monts DaY Year <br /> 1 8 Dreveparcy <br /> Pa DiwWa^YlMiwbon space ❑Ouanlin ❑rrPo ❑Ra"- <br /> 1 ❑Pamal RelecNon ❑Full Reprbon <br /> t&.Alte;rp@ Faddy l-Ca.'1eralorl Manaesl Reference Number: <br /> U U.S.EPA ID Numper <br /> W <br /> 15=SgraPtlAlremale Fadlty fa Gerwapx) <br /> Q <br /> ej MaMh Day Year <br /> y 19 Harer6Ns'Na&e Repg1 Managertxsnl Matlpd Cures li¢.¢odes for <br /> haxardWs waste heaeyrent.disposal,aM rerytling systems <br /> 1 <br /> 20 Desgnated FauFry pmin m Cperalor CeNfcadon of receipt olharertlws maladals mrered by the manilesl evcepl as raped In Item 19a <br /> Pmyedrpyped Name <br /> Sgnalure <br /> EPA Form 8700.22({tev.3-05)Precious etlltions are obsdeleMcn:t1 Day Year. <br /> GENERATOR'S INITIAL COPY <br /> Lydia Baker, EHST Page 55 of 55 <br />