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800 W. Mossdale Rd. Record ID# PR0514467 <br /> 8/5/2020 Program: HW <br /> Photo 16: The following uniform hazardous waste manifest (018170163JJK) observed with no signed copy from designated facility. <br /> -- —•a r rrirv� tu��. <br /> r ✓"+Fwe Arms oe (Fam <br /> 'f �, I rrrr>FORM NAtaftPO11S 'Gsrev ro ry ] � 16O31 <br /> ASTE YARIeEe.S�pT <br /> SGete.an.F VIM C9'1 r�u19�Mfw RA4wewnRYgd�n1 l� 1 � <br /> FJ7 9•J Yl kir r'N Mi c�tiS)0.�-�L+rS - <br /> Grwamrenecn, `0997 FFG rA RTfW' r:A <br /> Do2f. <br /> -.-A7a1i <br /> i � v ""��-i,"°"">"a""r•,w�A[n7nU serrwces O <br /> J > •�aw�.a aa,wn rwn. v.s.evn raeee• <br /> A 715 All OOTL F Al IF <br /> rrxti ANr)F LF.3 iA 'al)pnR <br /> F Prete_ (391.7715W <br /> ge. W.u3i iD..IaWr(Y'^�mV Rooer9hlpplry Nwn,Heard G4n.IO F�s�Y¢. fo.Cveaxars }}.7-1 t2.unn 19_wasle Cures .� <br /> r It HY .ndveaarvm—frill rro TVPe ou. n4I, • <br /> _ $ 11111i IIAZAR00115 WASTE SIOLl01 TIRFASFI <br /> I r ` <br /> t a �: <br /> 14.Si Handling rnso-uceons Intl Addihonal Inf—tion <br /> 1-800-424 9300*OFtS TERMINALCERE9 CS 'PROf11-E N DIV 5910R6T 09r- >iE r`• <br /> r '. .PE FntfIPM1ArN'r f – <br /> GEMERATOR'SfOFFEflOR'a CERTIFfCATION:!Hereby deGare that the cgntenls of Nls consignment a*e full and accuralely dearnbed al by ibe VIN—hi name,old Ira Gas ad�`xa9ed' r"`.' <br /> L ` z naked Intl labeleNpN—dod.and a rein all laspe U in proper condition for transport according to applicable mtemalanal andnalianal governmental mrgalannIrvO export ah pmBnt and}am he primary <br /> - 4 W EKWrW l cel Ill ere cwilenls of Nis consignment confi]ml to the terms of the attELhed EPAAduroWedgmeM of C.ansent. <br /> I carnry that Ne waste minlmirahon stltemi idem In 40 CFR 26227(al(if I am a large q-1 general,,r(h)iii V am a small quantiq genelalorl is true. <br /> ra`4i Generalu/s/ORerors Pnntedrfyped Narrre <br /> Signature Month DaY Year <br /> d n0- <br /> +*i ¢ i6.infematlonal Shipments Impind W U.S. ❑Export tram U.S, Portaf enlrylexil. <br /> w ZDate leaving U.S.: <br /> y W Transporter signanrre(for exports only): <br /> r s x a 17.TranspotKAcknoM-dgmenl ofReaip[afMa[erials Yaar <br /> Transporter 1 PrinM VTypad Name <br /> SlgnaWre µonlh Day , <br /> DaY Year <br /> i Transporfer2 Pnnledlryped Name SignaWta <br /> a C <br /> R ~ <br /> I 18,Discrepancy <br /> . A i8a,ofscrepancy Indication Space ❑Ouenlfty ❑Type ❑Residue ❑pardal Releclm ❑Fu4V Rajactivn <br /> Manliest Reference Numhel: <br /> U.S EFAVD Number <br /> . R � 186.Altemafe Facility(or GeneraldrJ <br /> U <br /> 1 <br /> lei i ifilyrs Phone: Mona gay Year <br /> { t18c.Signature olFdfemale Facility ill Generator) <br /> ;411 <br /> r <br /> Z <br /> C7 14.Hazardous Waste Report Management Mafhod Codes(l.e.,codas for hazardous Waste treatment,disposal,and Ieoycling Systems} <br /> p 2.. <br /> ' 20,Oesignaled Fasifily Owner or Operator:CeAiBcal of relci!of hazardous materials covered by the manifest alrapt as ndad in Item 190- ay Year <br /> ` PdntedlrypedName Signature <br /> EPA Form 870-27(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S iNVC1Al CORY 1 <br /> JASON GAITAN, EHS Page 16 of 21 <br />