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800 W. Mossdale Rd. Record ID# PR0514467 <br /> 8/5/2020 Program: HW <br /> Photo 11: The following uniform hazardous waste manifest (018233576JJK) observed with no signed copy from designated facility. <br /> t '�� Please pnni ortype.IForm designed for use on shin(12-pdch)bpewntar I Fun Appmved.17M5 No.2050-0034 <br /> r i UNIFORM HAZARevUe 1.Genammr 1.— 2.Page 1 N 3.Eme'gCnry Nasponse Prgna a.MaXMMTracFLq Number <br /> MIAGTE MANIFEST a l I3 U V:'l y.a'r• 0,1 i+ 3 157 6 JJK 4 <br /> 5.Gene.1Ma Name&ttl Maung Adliess GeneraWfs Silo Address Iif tlillerent man msaey Bddreaal <br /> rl <br /> Ixi Hive' iA 8GG�N t 7Gy:.OFLE rZa 1 <br /> - Geimrerors Pnona 2G3 32id,U4o i-ATiihGY '_ <br /> r ^ a.Tra.purhr l c-,ny Name U.S.EPAwyayrAer <br /> o sutitlkY I ROU'.'+ , <br /> 2.Tmn9pwfer 2 Cpnpany Name U.S.EPA IU Number pp II <br /> r <br /> 5 D-i lgnaed Feapiy Name ant SUAddmas u.s.EPA lqµumber <br /> Usk I:CILCX.iY YEftNVN INC <br /> 6 y 75 SOU 1 H feUYEE AVtNUE T <br /> IAA ANta -rW <br /> Fa <br /> th Phgm', .4':11--1 t-ji i l <br /> q.. Si U.S.DDT Di trrcludmd Proper Shippleg Name.H—d Class.iO Number. In.Containers 11.Total12.UAh 13.Wasffi Codes y i <br /> — HM end PxMrrg GmnPOWYal H. Type Ouan4ly WWd- <br /> _ _ � t_•ncN-P.CRA IdA�AfI.' ecFSFE,sGuF, •. ?5' �- 1 <br /> � r <br /> . z z <br /> [i FOR 3. <br /> 4. <br /> 14.Special Handling 1nMW bra end Addlaona!Infarmabon <br /> t.NIEii4:UIN w j UILMI HtL 1-&UU-424-a0duu WJ–t li. -- <br /> r( ( m '::'0630,.9 VILYSOUDS"P6000p0.5Cy905•APPROPRIATE Pli <br /> ®� 15. GENERATOR'SIOFFERUR'SCERTIFICATION:Ihereby led.,.that the eentenls ofrhls—gement are fully and axumlely dasoibed above by"piapar stripping name.and are dassfsd.paddii, <br /> marked andabsi'ai and are In all respells in proper edition for iaeonrong In eppl�ise inlemabonal and naoanal govemmenlal regulators.it expt and INt aNrear I am the ipoder. <br /> EsI certify that The contents of this_ignmant confe.U Ne terms.1the ell d EPAAdk,.Wadgmenl of Consent . <br /> I wroiy that t4 waste mmlmrzal+an statement identified In 40 CFR 2Q 271(it I am a large quanbiy genemim}ar @I(11 am a snag quantity 9anera4ml is hue. <br /> x'711 f i GarreratofsrQfferolS Piiniedffyped Name Signature i bay Year . <br /> a16.irnematona!Shipments ❑Ini m US� ❑Erpon from U.S. ri ft f enbyleait. <br /> Translsoder signi(Icr experts only): Date leaving U.S.: <br /> WrT-nTa <br /> Aorier 1 PrintedRypat Name SignaturBO <br /> orter2 PdnteNTyped Name $Ignature 6lonfn Day year <br /> 1 ~ <br /> fJisaeDaney <br /> I <br /> Alla.Uis�Tepancy lndirabpn Space ❑Quantity ❑Type ❑Residue ❑PaNai Rembrn ❑Full Re}edion �� <br /> ii <br /> Manliest Ra[erencX Number <br /> 18b.AAemato Fadliry(pr Ganerelor) U.S.EPA 16 Number <br /> 1 <br /> v <br /> LL Facilityas Phone, <br /> I <br /> t <br /> ofMamale Facility for Generator) ih Day Yeai <br /> I <br /> Waste Raped Managaie Melhpt Codes(La.,Dates for hazardous waste treilli disposal,and r"ding systems) <br /> t <br /> Facility Owner or Operator C0HI�IGltion of receipt of hazardous malelials e0veret ty the manifest 1111"1111 lien 111 <br /> l ame S gnalare a" ay ear ' <br /> EPA Forte$700-22(Rev.3'05)Previous ei are obsolete. GENERATOR'S INITIAL''JOV <br /> JASON GAITAN, EHS Page 11 of 21 <br />