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3276 Grant Line Road PR0543805 <br /> January 25, 2019 <br /> PHOTO 5: Manifest 018529411JJK was found without a si ned off co from the designated facility. <br /> long <br /> JJK <br /> 14.SpecNl Na^wing InMru <br /> _Myr r I coon and Aden;o�al lvlon^el,^n <br /> 16. me N�eWOR'WOFFEROR'g icERTIFIGTION:Thereby dedare mel tlx conlenN of Ul¢w <br /> rt�IM aM labeletllpNcapery and are in ell re¢peM¢in DinpermrNitpn for tra _^si9nmunl a�a lolly anb au—d ;.ebbed above byewq <br /> loe.y lcertay ryt0l MaaconMxU of UU conelgnmeM wnlorm Uthe Ulme oltlle eaa;hed EPAAhngMedgmenlol Consent.naeanU w�' opx aM1V,pvgnanw.art.qe gayityo.lyyago. <br /> I cerely mal Ne waeU ml Imiaa.tlon eUUmenl ltlan0fied in a 0CFRM2,27(a)(riamaN g 'y1p1�NI repuUoms'It axl;on eM1q;rcva erAlam V,e <br /> GenwUls'011erofs PdnUd/ryped Name ryequantitygen" wtbl TNI am avmlll quantitygwnatglia We. <br /> E19neture IIAn,N 10M 1 <br /> I6.Intemalional ghipments ❑Import M U 5. y----E- <br /> 1'mnaporter signaNre(/or exports onlyl. ❑Expos MmU.S. PwlNenvyleah:_ __ <br /> W 77.irensporterAcknowle0gmenl of Re:eipl of Malelials DaN leamq US.: <br /> O Transporter i gdnted/iyped Name <br /> signaNre Monm D. <br /> 6 <br /> QTrensporter2 PnnledRypel Name Signature <br /> Discrepancy <br /> I 19a.Discrepancy Indication Space Ouanlity ❑7ype ❑Residue ❑PaNal RejaU'wn ❑FUN Relaa;m <br /> blandest RAamnce Number. <br /> 18b./Utemale Facillly(or Generator) U.S.EI'AID Naebv <br /> J <br /> a <br /> 3 Facility's Phone: <br /> j iBc.Siemate Facility(or Generato <br /> gnature oUUtr) JI <br /> S19.Hazardous Waste Report Management Method Ct>des(i.e.,cedes for haulydous waste Vealmen4 dlsl>osa1 rd ing sysle,ms) <br /> 1. <br /> 4. <br /> Mmdl Day Year <br /> 20.Designated Faculty Owner or Operator.CeAification of receipt of heuNolra materials covered by the ms 9�sNfeapl as ndad in Ilam tea <br /> Pdnied/f'yped Name L <br /> GENERATOR'S INITIAL COPY <br /> ons 87L8700-22(Rev.3-05)Previous editions are obsolete. <br /> e uuc tRGES FOR LEGAL X 1-PRIM NA 11 <br /> LH <br /> 'ACC 11000 Fl L HALIDES,Of' <br /> 3A <br /> ,IN <br /> /PM <br /> Lydia Baker, REHS Page 5 of 5 <br />