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800 W. Mossdale Rd. Record ID# PR0514467 <br /> 8/5/2020 Program: HW <br /> Photo 13: The following uniform hazardous waste manifest (017467873JJK) observed with no signed copy from designated facility. <br /> 5 ' <br /> r � <br /> t9 <br /> �measa pnnl or Fom,Heal lar tree an sills 121AI h -ten Form ad.OMB No.2650-0u]9 <br /> UNIFpflM RA2ARW11S 1 Uannalor in Hurter 3.Pepe t of ].Emeryercyse Prwie a- khq ..q <br /> WASTE MANIFEST r:A L 0 V O:}�4 j �•.���'.•Respon.�_ ' ,, d T A 0-13 JJK <br /> 5 Ge,gnbh Hemp W IHaRym Aypan C>an.rebf�Sru Pedrea Irr GllenM W n mart�q�Nraafl <br /> r ln•owr.vena r <br /> P r� w�A xce <br /> rariri/n?F c:A n5a:p,r ,. .. ...L i.h.. <br /> �,erarara Pbay. iia9 s:l ivJi4 ,.I ��,.a;'•: <br /> A.Tnnapdhr 1 Camparly Nem, - <br /> V 5.EPA rD <br /> Tranepwer2Cmnpeny d NMtNumO�� y <br /> Wl lfr,rl l�Il.t NVi PIN I AL tit.rMGFa <br /> 7 Name U5 EPA IU N—.1 <br /> 1 <br /> B eeslgnelod Fa Jhry Nema sod$iN Atldraea U 5 EPA ro NamGar <br /> Fanai sPhona, <br /> gg. ab U.S,OOT Oesalor.Blade,Pa rShppinp Na—,Nazyd Glace,Ip Number, 10.Canlniirers 11.Tdi 12.UM 13 WasW Gomes <br /> rr1 em vaa"11 Craw(d enylY Ne. type oaanmy wl nrm <br /> 0 1 Nuly-aA;rtA 1*A:Auuuuy wault °�r_ar.tu r•.Ir}1��,� � � T� � <br /> 4a <br /> w 2 i <br /> 1 <br /> 3. <br /> 4. 1 <br /> F � <br /> 14,Special Hmtdarg mswctms antlAtltllaonal Infonnsaon <br /> C.ME h'L-t til;r CVNIAGL�I:lit"E"r 1-8VL"-'4-y3VU WV TlNNF1NAL G"FtN:i I;S •irH(IF ILY M`JB7.'D'.at1ti67 GRFARt <br /> "1AXMAP058055'APPROPRIA3 E PERSar A].f H'A EUI WE Fgl101MEN f <br /> 15 GENERATOR'=FFEROR'6CERTIFICATION; hereby daclam Nat lilacontents dNtls eonsignmanlare May and axaretaiy eascdbad above aY thB p[agar NiPPln9 mama,erd era tlassdred,packaged. <br /> maMed antl labeledlplawrded,antl are m all respects In proper pondllian for transport acwNing W epplirable Inlemetienaland national goremmenlal rerttyaptrna.Ir Bxpod ehlpmentand 1 amthapnmary <br /> Exremer,l.`11l r lhal she oanlents of 114'eadgnmenl contorm to the WMs of Ne attached EPAAcknawledgmenl of Consent <br /> I ceNty Nal Ne waste minimiraaonstatement idenarietl in 40 CFR 2&227is)(if I am a large quantity generatat m(67(Iii am asmalV quantity genaralor}'w We. <br /> GeaeratorsiDfferors PnnledRyped Name Glgna 94/ f ' <br /> r NNi� <br /> 16.In1ernaaonet 6hlpmenls - <br /> ❑ImportlaU.S. EKpod hom U.S. Port of en4yleair. r <br /> Transpoder slgnalure(for exports only) Data leaving ll.6a i' <br /> w 77.TranspprterA[kurpv/lerlgmem of Receipt of Materialsa1 r <br /> Transporter 1 Primedir ped Name E�66m <br /> w Signature <br /> a �7l~. <br /> = 7ransPoner2 Pdntedrfypad Name Slgnalure Month Day Year <br /> 111}}} 18.Glscrapancy <br /> I I 18a-OisaapancyIndicalron Space L]Guanuty ❑Type ❑ResWue ❑ParUaV RejBc4ion ❑Full RelecNan <br /> f III Msnliesl Reference Num4er: <br /> 1 <br /> 115EPA1D Numher <br /> 18b.Nlernate Facility{or Generator} . <br /> 1 <br /> U <br /> 9 Facility's Phpner Month Day YearLU <br /> ear <br /> 18c.Sgnalure olAflemale Facyily{or Generzlor� <br /> J Z <br /> 19.HaYaldpus Waste Repod Manana—rri Method Codes it e.•codes for hazardous weate Saatm irl,dispusal,and recycling systems) <br /> 0 1 7. <br /> 5 d <br /> 'S) 20.Designated Facility Owner"dr Uperalor CerGflcallon of receipt of hazeNaua materials covered 4y the manilas!except as tided in Item 18a Month Day Yenr <br /> i <br /> Prin*Jyped Name Ignalure <br /> EPA Form 87170-22(Rev 3.05)Previous edilions are obsolete. GENERATOR'S INITIAL COPY )PY <br /> ' J <br /> JASON GAITAN, EHS Page 13 of 21 <br />