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E. 41h St. Record ID# PR0514018 <br /> 9/2/2020 Program: HW <br /> Photo 28: The following uniform hazardous waste manifest(000247202DAT) observed lacking a signed copy from designated facility. <br /> - Pie.prinl 0,r tyype� Farrn Approved.OMe Na.205l)-1 2050 0039 <br /> --- VNIFORN '�aaaNla ]Ganvabr 1p 6amip.. 2 Pape 1 N 3E— Nnp�r�Plwib ��Mnan11ra1ryTr+nl�ln�pyf�y7m �Y�} �� <br /> WAS TE IN4NIFE5T f.Ap9Rz471 R58 gO6.63.-i$:53 �1O l7 Z�I f r'J G DAT <br /> 5.C+e�emofa Nan,s W Meurmq,aadrass ' <br /> nTTN Darien Rloelro �mr*n 25 <br /> -t whru an mxilug wmessl <br /> �a East dmmemaart Gala Eel Fourth St n 2o7�Y 000301 <br /> R al r_A 9�� - 222 <br /> .CA96366 s7✓ <br /> ca�r,raa w,v,a. �' <br /> 6.TranapwEar 1 O�rn210g-gyg-6131 V.S.EPalb Number (^�O <br /> yaTa (Saal�rrsertlO ••••ERI PIiO1VE-CvrrtIDN 97'86-0004••••1CPR00077874-1 �J <br /> i.irensppr9r 2 CoprpyrY Nema V.3 EPn Ib Number t <br /> CAlrartlECA�D982623433 <br /> rlNrmmerlls!SerNceb <br /> a Oee+wrelea Faurry Name a„d srm Aaanxs u.S.EPa to Nunme. <br /> 5526 DICO�OnO Pr4ronrid nhH Solutions Ill INR000127621 <br /> Rd <br /> Pormps.IN 46388 <br /> Fad sPrb„e: 260-240,2461 <br /> 9k ell U.S.DOT 00—illt n(IncWdlWPrlyerailip0n Nemo,N—nl Class.ll 10 <br /> l11.7oW '2 UMI t3 Was,�Ccdes <br /> HM -MPaCiMG— prenYp [ No T, Ouanhly WI Not. <br /> 1 NolRCRA Hazardous Nhste 9d Id(0IATOMeCE01A EARTH 352 <br /> o CLEAN UP <br /> a� <br /> w 2 <br /> s� <br /> a <br /> 4 <br /> I <br /> 14.Special Handling InsWcljdns andAddidonal Infonnalirn l <br /> D86969 SO 1839131 <br /> 1)100017l i 4�1- <br /> Cr <br /> Contradraeel <br /> �rnadbygenemilwnlersageracyaldhoittyonlnitransportertoaddorsu6efiWtaaddYonaltTanspol'1lRan MOratorrhehaM <br /> 15. GENERATOR'SfGFFEROR'S CERTIFICATION:Inerebydeaare matthe contents of this consignment are WllyaM acculalely desGided ahwe h'l ure pr.Pershipphtg name,ab are Cass�bed,pec%egad. 1 <br /> marketland laheled1placarded.and are in all respects Inproperwndibonfortransportacwlding to applicable rle oloralandnationalgovem tel Mull II capon shlpmenl anal aan the Prhnery <br /> red Erponer.I' ly Thal the Game,,s ofthis nansig—l'It wnform W the terms 001ea1Lached EPAFwNnoy6adramenl of Cm ell. <br /> M I oemfy Ill the waste minimization stl identified in 40 Cl 262.27(.){H l am a largo gpanSTy generaWr}or{b}(AI am a smart quantity generatnrlls uue. <br /> GeneraloY rots PnntedlTyped Name _ Signal Wil Day Y— <br /> :n[In ,1 16..Inlemationa15nipments — <br /> r of i— ❑Impod to U.S. ❑EaPod from U.S. PoRoI eniryfeaiC <br /> ? TmnsponeasignaNra rorexpOrtaonJy): Date leaning U 8: <br /> 17 Trans nerAcknowled mento(Reoei I°iMatedals <br /> diad m po g P <br /> ins the Trdnsppner I Pnna&lry�ame signature tdomh Day Year <br /> l' 7 <br /> d <br /> s i Transporter 2 PnntedlTYHed Name Slgnalure Mo in Day Year <br /> 4 <br /> ne.and 0 <br /> A proper 1a.Discrepancy <br /> rental <br /> 180,.Discrepancy Ipolcalion Space ❑T e ❑Residue ❑Panlal Rejedibn ❑FuA Refection 01 <br /> - ]Neots of ❑Quantlty YP <br /> Consent." <br /> INS party Mantles!Reference Number, 02 <br /> It. tab.Allendale Facility(w Generator) U.S.EPA D Number <br /> ;gnature _� 017 <br /> rte v � <br /> j' pyee Or Q Facility's Phone; Wrl Day Year <br /> f w 1 B Signature orklemale Facility[or Generalorf <br /> 15 maybe Q <br /> and Signing Z <br /> 19,Hazardous Waste Repot!Managemenl Method Codes(ie„codea for hazardous waste treatmenl,disppsat,and rucycBng systems) <br /> 0 1. 2. <br /> 20.Desgnaled Fadiily Owner or Operator Certification 0 recelpl0,r hazardous materials covered by the mandast except as noted In Item 16a <br /> Prinled/TypedName Sk naturE Month IIay Ye,ae <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S 1NMAL COPY <br /> JASON GAITAN, EHS Page 28 of 38 <br />