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7679 Longe Street PR0537564 <br /> December 28, 2018 <br /> PHOTO 19: Manifest 0111 78632JJK observed without a desi Hated facilit si ned off copy. <br /> Please Innt or type.(Foos designed for use on elite(12-Pitch)t"wnter.) Form Approved OMB No.2050.0039 <br /> p UNIFORMNAIIIRDOUS 1Generetor11 Number 2pagel of 3.Emergency Response panne 1.MmNeat Tonkin9,Num)ber 3 2 1JK <br /> WASTE MANIFEST , <br /> 5.Deneralols Name and MBTn9 Addrs Gearatoh Sita Mdress(ll ddlerenl than malfrg address) <br /> Generatoh Phone <br /> S.Transporter I Company Name U.S EPA In Number <br /> ].Transporter 2 Company Name U S.EPI ID rvumbrr <br /> S.Designaletl Faol ly Name antl Slle Address U.S.EPA ID Number <br /> Pacpiys Phone: <br /> 9a. Sb.US.00T Desnnplion linduding Proper Shipping Name HaxaM Class,IDNumber, 1g.(ivnroinen: "'T., 12.Unit <br /> Il.'A2sta Codes <br /> HM and Packing Group tdenyll No. Type Ouallbly NLNoI. <br /> 1. <br /> K <br /> aO <br /> K _ <br /> 2. <br /> (W'J <br /> 3. <br /> 4. <br /> ib.Special Handllnq lnsWNons and Additional lnfmma4on <br /> 15. GENERATORIWOFFEROR'S CERTIFICATION:I hereby declare Nat to cements ofNls mnsignmenl are fully and aw.ratay tleanbed above by to proper shippily name,aM are daaslhq d,packaged. <br /> marked andlabal"ptt—ded.and are in all respect in lmper mrNa b <br /> Nen la aotordirg to applicable intemagonal ant 1-11 govemmenNl regulations.Xexpod shipment and tem its Prim,, <br /> F ') <br /> Eodar.lceddy Nat Ne Inman,oftb mndgnmentwdon0 Ne tams of to addled EPAAr ,Idgmenl of Conant. <br /> I ce,y Nal to waste minimization statement idandfied in 40 CFR 2622](,)(n lam a targe guandry generohr)oro)oil am a small guanNy generator)is sue. 1 <br /> GenemblaKdfaW1 Pnntedfyml Name Slgratre Mont. pay Year <br /> 16.Inlemational Shipments ❑low to U S. ❑bw Bom U.S. P.O—,lexd:' <br /> Tronsponer signatre.(brexpons only): Date heroin,U.S.: <br /> -,-I -mot of Receipt of Materials _ <br /> �Tronsporterl PnnledlTped Name Siynatre I. Day Year <br /> n <br /> QTronsponer2 Pnntedliyped Name Signatre Monty Day Year <br /> ~18.Dismpanq —/I <br /> 1 18a 0is reps ylndir'no'Space EJouaney ❑Type ❑Resitlus ❑Partal Rel..7o El Full Refection <br /> Mantled Reference Number. <br /> 7St.Allemale Fadliyia Generetw) U.S.EPAID umber <br /> Qa6 110 Phone: --+—/ <br /> O 18u <br /> Sign aWre dFulegiate Fedlly(or Gneirden) h Day Year <br /> Q <br /> 2 <br /> m79.Ha]allous Waste F;epon Management ME.Cedes(i.e.,cedes krbaxanlous waste Veahnent,tlisporal,and regtlilg sysNms) <br /> low <br /> 20.Designated Fadhiy 0aner Or ONoeWr.CeNfiatlon of receipt of haxaraas matenahs wvered by the mS'Nest t-.It as nded in 11118a Mont Day Year <br /> II` posedrryped Name <br /> EPA Foml 8700.22(Rev.3-05)Previous edifions are obsolete. GENERATOR'S INITIAL COPY <br /> Lydia Baker, REHS Page 19 of 21 <br />