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940 N. Central Ave. Record ID# PR0513647 <br /> 11/10/2020 Program: HW <br /> Photo 10: The following uniform hazardous waste manifest (0 1 7696596JJK) observed lacking designated facility copy. <br /> pr—pnnI.,lyp¢.{From desg"d fwuseon Ote(12-Palk)typawdlar.} Form Approved.OMB No.2USO-0039 ' <br /> 2 Pa 101 3 Eme Response Phwe A.ManiFnt Trach' Numbx <br /> NNlFORN HAZARGGNS I.GwwmrarlDNumhr gn yawY �196�96 JJK W3O <br /> WASTE MANI€25 .Int D 0 3 1 U.19 b 1 �N1aU>41-0dSU� <br /> — R' SGe�embfs NameaMMaMpAadrma Gen WeS Sre Addroaa nIddrerent lhan WIW9 addmsa) <br /> -- r IY.f5151Yft ay;i6etr12 y.. <br /> F.. 9 ..+W H GEMI WJ.AVt <br /> L'A J5:i 1(S <br /> _$ ce„emmre Phnna. -�ti Za 1164 <br /> I11 6,Trans-r I CwnPan y Name U.S.EPA m Namb¢r Ir <br /> Luu[l cldS'fHVNMtN1AL SElh'ICt`3 I•A I'Iu'-1 <br /> rV 7.Trampoder2CmpenYNeme US.EPR Ib Number <br /> r .. 8 Designate0 FaNIIM Nama entl SHa Address 11.5,EPA ID Nembar + <br /> - r-s1^.SVuu1 el?n.t.rive WI1F. -nr�ua �v. <br /> r � .,FIri;FliF.y t,A r,A(Y11117 Cr3fr�y_5 <br /> Facill aPhona' '.:h-'if-1htNr <br /> ga 9b.U.5.GGT bas 1008(OdArrg Prgper SNPP N Name,Hamrd Clam Ib Number, 10 Cera vers 11.Tola1 12.bn6 13.Wsabr Godes <br /> HN <br /> and Packing Group(rf erw]] Nn Type Q¢anbty W1 Nol <br /> a r _ I <br /> 0 -HA HACANi17J1g+,i WASI E.SOLID(OIL AND ABSbRBEWTI <br /> �I 2 <br /> 4 <br /> } <br /> Id Spedal Mandang lnsWctionsanbAdTbanel lnfpmaran 4,h rf', <br /> EMEFrfiENCY 1;u/N FA1,1 CHLHiIH1G 14K*X24,g3WWCMMTEF&MNFIf,;(,`j3MCS NAt�, p!,bl ll, - <br /> AF{-rra.gr.7'rrl nor.^s'-interNl '^PS:KAVjO,1S M'"APPRDPR1ATE PER"AAL PHUTtME LQUIPMUiI . <br /> f e 15. GENERATOR'SIOrrERCR's CERTIFICATION:Iharaby dedarelnal the-tanlswlhistmlslgnmentare Fully and—mealy de-badaM'rebytlre proper ahippng name,are aredass160tl,9atFaged. <br /> z —kddarid laheledlP.IdO and.remall rasp.,11,1 proper—diuon Mrb nMW a-ldhg toeppllrablelntgmalitlgo.—,Talal and nat—go.—,Tal regulaliom.N eryan shipmentaMlam lha Primary <br /> Expoder,I—N Nalth¢-oleo's¢'lhle—19-11—1--W Natemisof Ne#Wuna4 EPR Aek-m gmant dConsent <br /> I Tardy Ilial thewaste—'Frazalion SUI-anl idankeed In 40 CFR 26237(.)(H I am a large quanbty ganerab r)or)b)(if I am a small quW,y geIML.1or)a true, <br /> GeneraloystORemrs Jnnytlmyped Nenre sigrv',wy ---�� Month DaY Year <br /> 16.Intemapana)$hiyrrlanl5 <br /> ( ❑Impar'to u8. ❑bp¢d from U.S Pad of erdyi—_ <br /> Trenepoher signature(for a Kme only). Gay IeaMngU5: <br /> ' W }7 TranapMer Atlrnowlfadgmenl of RerEipl of Maynals <br /> - Tranepoder I PnnletlI7Yped Hama SignalNre <br /> t d Month Day Yeal <br /> Tmnapw1912 Pnnledrtypad Name I Signature <br /> MorAI Gay Year <br /> r la o�eerep.ny <br /> w' <br /> * 1+ IBa.➢ISaepanryingicallon 5paG¢ ❑I� <br /> ❑Ou.nldy Type ❑Residue <br /> ❑ParLal gajeclion LI Full Re)eclion <br /> TEL Allem.le F.[,JIN(or Ganeralpr) hlandesl fieler¢rAe Number, <br /> U US.EPR V6 Numbe+ � [ <br /> LL Fa61,[Ys Phone: •� <br /> I&.Sigmtun&.?ANMate Fatally(¢r Generelor) <br /> W <br /> Z Monty Day year <br /> - N 19 nazartlous Waste Reppd Monagamenl Memod Codes(I e,mdesfir lyaartlpus waste beaunenl.tllsposal,and iecytllnA systems} <br /> s <br /> 3. 4 �' ♦. <br /> 29.Oasignated Facdllry Owner w Opemlor Cndifoalmn ql receipt nl hazallousmeledals coverodb No ~y _ 4 . <br /> �; Pdnladfpyped Name y memfeel eacepl as ngatl In Item tNa <br /> 5�gna)ure _; <br /> Month ay Year <br /> EPA Form MD-22(Rev.3-05)Previous editions are obsoEele. <br /> GENERATOR'S INITIAL COPY <br /> r <br /> JASON GAITAN, REHS Page 10 of 19 <br />