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1189 PHINNEY'S LANE - Health (2)
189Phinnys Lane Hyannis 4 o I ° P P " " P No. Fee Z S/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �ppii ion for ]Disposal 6psteut you trurtiou Permit Application for t C nsV Rep it ) Upgr ) Abandon ❑Complete System ❑Individual Components Location Address o o ®I IV Owner's Name,Addre and M-No. ts eskf'S M P; I v2 / _ 63 Vm2adr / G Installer's Name,Address,and Tel.No. a{y� Designer's Name,Address,an Te o. Type of Building: 7 "73?-9�t0 O/ Dwelling No.of Bedrooms 0 Lot Size l•CCP'Jsq.ft. Garbage Grinder( ) Other Type of Building 1"14-41164 /1C, No.of Persons Showers( ) Cafeteria( ) Other Fixtures ® GG Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) CpYuri E71� 11- cx 11. Date last inspected: Agreement: The undersigned agrees to ensure the construct/nandma�iEance of the afore described on-site sewa a dis osal s stem in P� �' g P Y accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by oar 5� d ✓ Date p q 1 ./ 3- Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. < Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ; Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS / C applitation for Disposal fpstetn ion truction Permit r � Application for t to�Co srt truc (�) Repair( ) Upgrade( ) Abandon ❑Complete System ❑Individual Components Location Addres o o V v _/ ll� Owner's Name,Address,and Tel6 6 P .No.5e5550 eg1ldE'Ma °arc`e� a 6 3 .. Gts Installer's Name,Address,and Tel.No. Designer's Name,Address,andtTel.No. f JAA Type of Building: Dwelling No.of Bedrooms Lot Size ./ &_ .Ssq.ft. Garbage Grinder( ) Other Type of Building ftit l) %G> /t No.of Persons tXo Showers( ) Cafeteria( ) Other Fixtures �G Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil c Nature of Repairs or Alterations(Answer when applicable) So,uj e.r C o n—n ec-.4i, Date last inspected: o ��'` 40 Qp-,,i:i_,A UI O i Agreement: And cr rCThe undersigned agrees to ensure the constructiJm�aiintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ,. Compliance has been issued by t • Boar o 7b 1 Date Application Approved by Date �7 v Application Disapproved by Date for the following reasons Permit No. i Date Issued — TIC F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage isposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned.l�)tty�} ! ", #af, is x r'r is _ /pia c cted in accord, ce with the provisions of Title 5 and the for Disposal System Construction Permit No ��"' J Installer ;nr�f may//�1L/�/�� Designer #bedrooms Approved desi ow d The issuance of this ermThe issuance of this erm' /sEll not be construed as a guarantee that the system w' l�unc io j desi/fined. i/ vrw;�) Date Ins ector : / --- --------------------r--------_------------------------------------------------------------ —------------------------------- ' No. � Fee v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Vermit Permission is hereby granted to Construct( ) ,Repair( Upgrade( ) Abandon -4�_L.., System located i f }� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConsV ttion mi/st be completed within three years of the date of this permit. Date �/ Approved by i. �AA41 General Chemical Corp . 133 Leland St.Framingham MA 01701 PHONE: 508-872-5000, FAX: 508-875-5271 Land Disposal Restriction Notification and Certification Form Generator: TOWN OF BARNSTABLE Manifest Number: 3665 EPAID: MP5088624645 / Manifest Tracking Number: ppd 3 95 ✓A The EPA hazardous wastes identified below must be treated to the applicable treatment standards Set forth In 40 CFR 268.40. w EPA Waste Code Information Manifest LineWaste- EPACodes water? Page 1 Line 1 No D002 Page 1 Line 2 No D002 Page 1 Line 3 No RCRA non-hazardous Underlying Hazardous Constituents (None present unless identified below.) anifest Constituents Line I certify that all information submitted On this Land Disposal Restriction and Certification Form is accurate and complete, to the best of my knowledge and information. Signature: Name: Title: Date: I n r lChemical F e a Corp . and St.Framingham MA 01701 PHONE: 508-872-5000, FAX: 508-875-5271 Land Disposal Restriction Notification and Certification Form Generator: TOWN OF BARNSTABLE Manifest Number: 3664 EPAID: MP5088624645 Manifest Tracking Number: ?9 gy The EPA hazardous wastes identified below must be treated to the applicable treatment standards Set forth In 40 CFR 268.40. EPA Waste Code Information Manifest LineWaste- EPACodes water? Page 1 Line I No DOO1(High TOC ignitable li uids subcategory)DO18 Underlying Hazardous Constituents (None present unless identified below.) anifest Constituents ine I certify that all information submitted On this Land Disposal Restriction and Certification Form is accurate and complete, to the best of my knowledge and information. Signature: Name: Title: Date: General Chemical Corp I 133 Leland St.Framingham MA 01701 PHONE: 508-872-5000, FAX: 508-875-5271 Land Disposal Restriction Notification and Certification Form 1 Generator: TOWN OF BARNSTABLE Manifest Number: 3663 EPAID: MP5088624645 Manifest Tracking Number: Y56 39.E U1k The EPA hazardous wastes identified below must be treated to the applicable treatment standards Set forth In 40 CFR 268.40. EPA Waste Code Information Manifest LineWaste- EPACodes water? Page 1 Line 1 No P075 age 1 Line 2 No NONE Underlying Hazardous Constituents (None present unless identified below.) Manifest Constituents Line I certify that all information submitted On this Land Disposal Restriction and Certification Form is accurate and complete,to the best of my knowledge and information. Signature: Name: Title: Date: ! Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number (i WASTE MANIFEST t` 5091362464 #. r.°... . '" t" 3 a 83 9 -Q 3 JJ K 5.Generators Name and Mailing Address lARM " �i 9 (},tj*€)Ll $.fit k ' xw'�,�5�.i��E nerator's Site Address(if different than mailing address � FW MAIN `:.i°!'1 EEX HEiti3t.TH €�IVISSI�;N 1IE49 #"HINW-V LAK' fHeA'A Fs BARNRTABLE, NA 026TI -MA Generators Phone: 6.Transporter 1 Company Name . . umber CLEAN VENTURE, INC. 7.Transporter 2 Company Name U.S.EPA ID Number I 8.Designated Facility Name and Site Address ) l.`II 7 ; U.S.EPA ID Number 21`f y-y�r�r#U�yirpH F l Ki f gSyTE'Sd EFT ? Facility's Phone: ) �a"JIS Nlr12P�IF� j ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. , X 1.ftste Nlcokirie 6.1 UN1654 PU X1 o ERGO 151 u, Z 2. (� � ' t�""tt � i �s�,Ck«'. ;•att'�kin. �Ja�1°(�Qilt,N`4 ?r"ya ►� NME W 3. I 4. I I i 14.Special Handling Instructions and Additional Information r 114 .�f 4 t� fly f i (I)LAYP MICUI INE L{P 2yC R I T'E5T1CI i 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, I marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generatofs/Offeror's Printed/Typed Nam_e ,r Signature Month Day Year 1 ❑Import to U.S.16.International Shipments Ex en /exit: ' ❑Export from U.S. Port of try Transporter signature(for exports only): Date leaving U.S.: i 17.TransporterAcknowledgment of Receipt of Materials i W Transporter 1 PrintedlTyped`Name Sig ature y Month Day Year 00 3 r.1, i Z Transporter 2 Printedfryped Name Signature tw u Month Day Year � ~ i 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type� El Residue El Partial Rejection El Full Rejection I IManifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedfryped Name Signature Month Day Year ;I i i EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY 9q a U.S.EPA Form 8700-22 Item 10.Containers(Number and Type) Read all instructions before completing this form. _ - _ Enter,the number of containers for each'waste and,the appropriate abbreviation from Table I 1. This form has been designed for use on a 12-pitch(elite)typewriter which is also compatible (below)for the type of container. with standard computer printers;a firm point pen may also be used-press down hard. TABLE I.--TYPES OF CONTAINERS - 2. Federal regulations require generators and transporters of hazardous waste and owners or BA=Burlap,cloth,paper,or plastic bags. DT=Dump truck. operators of hazardous waste treatment,storage,and disposal facilities to complete this form CF=Fiber or plastic boxes,cartons,cases. DIN=Wooden drums,barrels,kegs. (EPA Form 8700-22)and,if necessary,the continuation sheet(EPA Form 8700-22A)for CM=Metal boxes,cartons,cases(including HIS=Hopper or gondola cars. both inter-and intrastate transportation of hazardous waste. roll-offs). ' CW=Wooden boxes,cartons,cases. _ TC=Tank cars. Public reporting burden for this collection of information is estimated to average: 30 minutes for generators,10 CY=Cylinders. TP=Portable tanks. minutes for transporters,and 25 minutes for owners or operators of treatment,storage,and disposal facilities. This DF=Fiberboard or plastic drums,barrels,kegs. TT=Cargo tanks(tank trucks). includes time for reviewing instructions,gathering data,completing,reviewing and transmitting the form. Any DM=Metal drums,barrels,kegs.- - -- correspondence regarding the PRA burden statement for the manifest must be sent to the Director of the Collection Strategies Division in EPA's Office of Information Collection at the following address: U.S.Environmental Item 11.Total Quantity Protection Agency(2822T);1200 Pennsylvania Ave.,NW.,Washington,DC 20460. Do not Send•- -• Enter,'in designated boxes,the total quantity of waste. Round partial units to the nearest the completed form to this address. whole unit,and do not enter decimals or fractions.'To the extent practical,report quantities using appropriate units of measure that will allow you to report quantities with precision. 1 I.Instructions for Generators Waste quantities entered should be based on actual measurements or reasonably accurate Item 1.Generator's U.S.EPA Identification Number estimates of actual quantities shipped. Container capacities are not acceptable as estimates. Enter the generator's U.S.EPA twelve digit identification number,or the State generator - - Item 12.Units of Measure(WeighWolume) identification number if the generator site does not have an EPA identification number. Enter,in designated boxes,the appropriate abbreviation from Table II(below)for the unit of Item 2.Page 1 of __ _ w _. measure:. _ _ - Enter the total number of pages used to complete this Manifest(i.e.,the first page(EPA Form TABLE II.-UNITS OF MEASURE 8700-22)plus the number of Continuation Sheets(EPA Form 8700-22A),if any). G=Gallons(liquids only). N=Cubic Meters. Item 3.Emergency Response Phone Number K=Kilograms. P=Pounds. Enter a phone number for which emergency response information can be obtained in the event ` L=-Liters(liquids only). - T=Tons(2000 Pounds). of an incident during transportation. The emergency response phone number must: M=Metric Tons(1000 kilograms). Y=Cubic Yards. 1. Be the number of the generator or the number of an agency or organization who is capable Note: Tons,Metric Tons,Cubic Meters,and Cubic Yards should only be reported in of and accepts responsibility for providing detailed information about the shipment; connection with very large bulk shipments,such as rail cars,tank trucks,or barges. 2. Reach a phone that is monitored 24 hours a day at all times the waste is in transportation Item 13.Waste Codes (including transportation related storage);and ' 3. Reach someone who is either knowledgeable of the hazardous waste being shipped and Enter up to six federal and state waste codes to describe each waste stream identified in Item has comprehensive emergency response and spill cleanup/incident mitigation information 9b. State waste codes that are not redundant with federal codes must be entered here,in for the material being shipped or has immediate access to a person who has that knowledge addition to the federal waste codes which are most representative of the properties of the waste. and information about the shipment. , Item 14.Special Handling Instructions and Additional Information Note: Emergency Response phone number information should only be entered in Item 3 when there is one phone number that applies to all the waste materials described in Item 9b. If a 1. Generators may enter any special handling or shipment-specific information necessary for situation(e.g.,consolidated shipments)arises where more than one Emergency Response the proper management or tracking of the materials under the generator's or other phone number applies to the various wastes listed on the manifest,the phone numbers handler's business processes,such as waste profile numbers,container codes,bar codes, associated with each specific material should be entered after its description in Item 9b. or response guide numbers. Generators also may use this space to enter additional . Item 4.Manifest Tracking Number _, _ - descriptive information about their shipped materials,such as chemical names,constituent percentages,physical state,or specific gravity of wastes identified with volume units in This unique tracking number must be pre-printed on the manifest by the forms printer. Item 12. r Item 5.Generator's Mailing Address,Phone Number and Site Address 2.This space may be used to record limited types of federally required information for which Enter the name of the generator,the mailing address to which the completed manifest signed there is no specific space provided on the manifest,including any alternate facility by the designated facility should be mailed,and the generator's telephone number. Note,the designations;the manifest trackingnumber of the original manifest for rejected wastes and telephone number(including area code)should be the normal business number for the residues that are re-shipped under a second manifest;and the specification of PCB waste generator,or the number where the generator or his authorized agent may be reached to descriptions and PCB out-of-service dates required under 40 CFR 761.207. Generators, provide instructions in the event the designated and/or alternate(if any)facility rejects some or however,cannot be required to enter information in this space to meet state regulatory all of the shipment. Also enter the physical site address from which the shipment originates requirements. only if this address is different than-the mailing address.' Item 15.Generators/Offeroes Certifications Item 6.Transporter 1,Company Name;and U.S.EPA ID Number - 1. The generator must read,sign,and date the waste minimization certification statement. In Enter the company name and U.S.EPA ID number of the first transporter who will transport the signing the waste minimization certification statement,those generators who have not waste. Vehicle or driver information may not be entered here. - i _ been exempted by statute or regulation from the duty to make a waste minimization Item 7.Transporter 2 Company Name and U.S.EPA ID Number certification under section 3002(b)of RCRA are also certifying that they have complied .If applicable,enter the company name and.U.S.EPA ID number of the second transporter who - with the waste minimization requirements. The Generator's Certification also contains the will transport the waste. Vehicle or driver information may not be entered here. 'required attestation that the shipment has been properly prepared and is in proper If more than two transporters are needed,use'a Continuation Sheet(s)(EPA Form 8700-22A). condition for transportation(the shipper's certification). The content of the shipper's certification statement is as follows: "I hereby declare that the contents of this Item 8.Designated Facility Name,Site Address,and U.S.EPA ID Number consignment are fully and accurately described above by the proper shipping name,and Enter the company name and site address of the facility designated to receive the waste listed are classified,packaged,marked and labeled/placarded,and are in all respects in proper on this manifest. Also enter the facility's phone number and the U.S.EPA twelve digit condition for transport according to applicable international and national governmental identification number of the facility. regulations. If export shipment and I am the Primary Exporter,I certify that the contents of Item 9.U.S.DOT Description(Including Proper Shipping Name,Hazard Class or Division, this consignment conform to the terms of the attached EPA Acknowledgment of Consent." Identification Number,and Packing Group) _ _ When a party other than the generator prepares the shipment for transportation,this party Item 9a. If the wastes identified in Item 9b consist of both hazardous and nonhazardous may also sign the shipper's certification statement as the offeror of the shipment. materials,then identify the hazardous materials by entering an"X"in this Item next to the 2. Generator or Offeror personnel may preprint the words,"On behalf of in the signature corresponding hazardous material identified in Item 9b. - block or may hand write this statement in the signature block prior to signing the Item 9b. Enter the U.S.DOT-Proper Shipping Name,Hazard Class or Division,Identification - -generator/offeror certification,to indicate that the individual signs as the employee or agent Number(UN/NA)and Packing Group for each waste as identified in 49 CFR 172. Include of the named principal. technical name(s)and reportable quantity references,if applicable. Note: All of the above information except the handwritten signature required in Item 15 may Note: If additional space is needed for waste descriptions,enter these additional descriptions be pre-printed. in Item 27 on the Continuation Sheet(EPA Form 8700-22A). Also,if more than one _ - Emergency Response phone number applies to the various wastes described in either Item 9b or Item 27,enter applicable Emergency Response phone numbers immediately following the _ shipping descriptions for those Items. n Please print or e. Form designed for use on elite 12- itch typewriter.) Form Approved.OMB No.2050-0039 P type.( 9 ( P )tYP ) PP UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number !, WASTE MANIFEST MP51ME 624645 ( r-1) 8 2--r- o 0 0 0 8 9 J K 5.Generator's Name and Mailing Address TOW OF PM43 SABLE. Generators Site Address(if different than mailing address) i-00 MAIN .cMIXET WALTH DIVISION 119q i"HINMEY S LANE lei RRSSTABLE, M Wc?604 fdie Tt f.E q HA Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number ICi..EAN VENTURE. INC. # J01�f�E027193 7.Transporter 2 Company Name U.S.EPA ID Number II � 8.Designated Facility Name and Site Address General Chemical (.:c p. U.S.EPA ID Number 13-3 Leland Street Facilitys Phone: (509) i ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes Ix off, _ ,z 2' tte as >t t, filled Witt) ,aci,o 8 1#t42794 FAG3. fly t A Xi� t"�lf # ' y�Z'Rt.is _ ,9 t ;' r PS u 4. :Cr aF: 14.Special Handling Instructions and Additional Information LOR On File (?}LED-3 LEAD ACID A TERIE.-'s (3)m f 4EKikx I 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary C Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. i I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Geenerator'slOfferor'1s Printed[Typed(Name Signature ( r��,, (1� Month Day Year 1`1 t /).r4 r� }`f 1`t i1 tr ;'e'ho,j J 16.Inter 966al'Shipments `" ❑ or i F ❑Import to U.S. Export from U.S. `�.. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials j TranspVorteer 1 PrintedlTyped Name Signature s t' \ Month Day Year IL a Trnsport&2 ri tedfTyped'Name Signature ' " ` --' Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space i ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ LL Facility's Phone: ` w 18c.Signature of Alternate Facility(or Generator) Month Day Year Z II N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1.. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdntedrryped Name Signature Month Day Year I EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY U.S.EPA Form 8700-22 Item 10.Containers(Number and Type) Read all instructions before completing this form. _ Enter the,number of containers for each waste and the appropriate abbreviation from Table I 1. This form has been designed for use on a 12-pitch(elite)typewriter which is also compatible (below)for the type of container. with standard computer printers;a firm point pen may also be used—press down hard. I TABLE I:-TYPES OF CONTAINERS 1 2: Federal regulations require generators and transporters of hazardous waste and owners or BA=Burlap,cloth,paper,or plastic bags.R DT=Dump truck. operators of hazardous waste treatment,storage,and disposal facilities to complete this form CF=Fiber or plastic boxes,cartons,cases. DW=Wooden drums,barrels,kegs. (EPA Form 8700-22)and,if necessary,the continuation sheet(EPA Form 8700-22A)for CM=Metal boxes,cartons,cases(including HG=Hopper or gondola cars. both inter-and intrastate transportation of hazardous waste. roll-offs). CW=Wooden boxes,cartons,cases. TC=Tank cars. Public reporting burden for this collection of information is estimated to average:'30 minutes for generators,10 - CY=Cylinders. TP=Portable tanks. minutes for transporters,and 25 minutes for owners or operators of treatment,storage,and disposal facilities. This DF=Fiberboard or plastic drums,barrels,kegs. TT=Cargo tanks(tank trucks). includes time for reviewing instructions,gathering data,completing,reviewing and transmitting the form. Any -.DM=Metal drums,barrels,kegs: correspondence regarding the PRA burden statement for the manifest must be sent to the Director of the Collection Strategies Division in EPA's Office of Information Collection at the following address: U.S.Environmental Item 11.Total Quantity Protection Agency(2822T),1200 Pennsylvania Ave.,NW.;Washington,DC 20460: Do not send 'Enter,in designated boxes,the total quantity of waste. Round partial units to the nearest the completed form to this address. whole unit,and do not enter decimals or fractions. To the extent practical,report quantities using appropriate units of measure that will allow you to report quantities with precision. I.Instructions for Generators Waste quantities entered should be based on actual measurements or reasonably accurate Item 1.Generator's U.S.EPA Identification Number estimates of actual quantities shipped. Container capacities are not acceptable as estimates. Enter the generator's U.S.EPA twelve digit identification number,or the State generator Item 12.Units of Measure(WeighWolume) identification number if the generator site does not have an EPA identification number. Enter,in designated boxes,the appropriate abbreviation from Table II(below)for the unit of Item 2.Page 1 of _ ! _ measure. r Enter the total number of pages used to complete this Manifest(i.e.,the first page(EPA Form TABLE II.--UNITS OF MEASURE 8700-22)plus the number of Continuation Sheets(EPA Form 8700-22A),if any). G=Gallons(liquids only). N=Cubic Meters. Item 3.Emergency Response Phone Number t 9 Y p K=Kilograms. P=Pounds. i Enter a phone number for which emergency response information can be obtained in the event — L=Liters(liquids only). -' T=Tons(2000 Pounds). of an incident during transportation. The emergency response phorie number must: M=Metric Tons(1000 kilograms). Y=Cubic Yards. 1. Be the number of the generator or the number of an agency or organization who is capable Note: Tons,Metric Tons,Cubic Meters,and Cubic Yards should only be reported in _ of and accepts responsibility for providing detailed information about the shipment; connection with very large bulk shipments,such as rail cars,tank trucks,or barges. 2. Reach a phone that is monitored 24 hours a day at all times the waste is in transportation Item 13.Waste Codes (including transportation related storage);and 3. Reach someone who is either knowledgeable of the hazardous waste being shipped and Enter up to six federal and state waste codes to describe each waste stream identified in Item has comprehensive emergency response and spill cleanuplincidentrnitigation information .9b..State waste codes that are not redundant with federal codes must be entered here,in for the material being shipped-or has immediate access to a person who has that knowledge addition to the federal waste codes which are most representative of the properties of the and information about the shipment. i - waste. Note: Emergency Response phone number information should only be entered in Item 3 when Item 14.Special Handling Instructions and Additional Information there is one phone number that applies to all the waste materials described in Item 9b. If a 1. Generators may enter any special handling or shipment-specific information necessary for situation(e.g.,consolidated shipments)arises where more than one Emergency Response the proper management or tracking of the materials under the generator's or other phone number applies to the various wastes listed on the manifest,the phone numbers handler's business processes,such as waste profile numbers,container codes,bar codes, associated with each specific material should be entered after its description in Item 9b. or response guide numbers. Generators also may use this space to enter additional Item 4.Manifest.Tracking Number _ _ descriptive information about their shipped materials,such as chemical names,constituent percentages;physical state,or specific gravity of wastes identified with volume units in This unique tracking number must be pre-printed on the manifest by the forms printer. Item,12. Item 5.Generator's Mailing Address,Phone Number and Site Address 2. This space may be used to record limited types of federally required information for which Enter the name of the generator,the mailing address to which the completed manifest signed there is no specific space provided on the manifest,including any alternate facility by the designated'facility should be mailed,and the generator's telephone number. Note,the designations;the manifest tracking number of the original manifest for rejected wastes and telephone number(including area code)should be the normal business number for the residues that are re-shipped under a second manifest;and the specification of PCB waste generator,or the number where the generator or his authorized agent may be reached to - descriptions and PCB out-of-service dates required under 40 CFR 761.207. Generators, provide instructions in the event the designated and/or alternate(if any)facility rejects some or however,cannot be required to enter information in this space to meet state regulatory all of the shipment. Also enter the physical site address from which the shipment originates requirements. 'only if this address is different than the mailing address. - Item 15.Generator's/Offeror's Certifications Item 6.Transporter 1 Company Name;and U.S.EPA ID Number _ 1. The generator must read,sign,and date the waste minimization certification statement. In Enter the company name and U.S.EPA ID number of the first transporter who will transport the signing the waste minimization certification statement,those generators who have not waste. Vehicle or driver information may not be entered here. been exempted by statute or regulation from the duty to make a waste minimization' Item 7.Transporter 2 Company Name and U.S.EPA ID Number certification under section 3002(b)of RCRA are also certifying that they have complied If applicable,enter the company name and U.S.EPA ID number of the second transporter who_ with the waste minimization requirements. The Generator's Certification also contains the will transport the waste. Vehicle or driver information may not be entered here. required attestation that the shipment has been properly prepared and is in proper If more than two transporters are needed,use a Continuation Sheet(s)(EPA Form 8700 22A). condition for transportation(the shipper's certification). The content of the shipper'si certification statement is as follows: "I hereby declare that the contents of this Item 8.Designated Facility Name,Site Address,and U.S.EPA ID Number consignment are fully and accurately described above by the proper shipping name,and Enter the company name and site address of the facility designated to receive the waste listed are classified,packaged,marked and labeled/placarded,and are in all respects in proper on this manifest:Also enter the facility's phone number and the U.S.EPA twelve digit condition for transport according to applicable international and national governmental identification number of the facility. regulations. If export shipment and I am the Primary Exporter,I certify that the contents of Item 9.U.S.DOT Description(Including Proper Shipping Name,Hazard Class or Division, this consignment conform to the terms of the attached EPA Acknowledgment of Consent." Identification Number,and Packing Group) When a party other than the generator prepares the shipment for transportation,this party Item 9a. If the wastes identified in Item 9b consist of both hazardous and nonhazardous may also sign the shipper's certification statement as the offeror of the shipment. materials,then identify the hazardous materials by entering an"X"in this Item next to the 2. Generator or Offeror personnel may preprint the words,"On behalf of in the signature. correspondinghazardous material identified in Item 9b:• block or may hand write this statement in the signature block prior to signing the -Item 9b. Enter the U.S.DOT Proper Shipping Name,Hazard Class or Division,Identification generator/offeror certification,to indicate that the individual signs as the employee or agent Number(UN/NA)and Packing Group for each waste as identified in 49 CFR 172. Include of the named principal. I technical name(s)avid reportable quantity references,if applicable. Note: All of the above information except the handwritten signature required in Item 15 may Note: If additional space is needed for waste descriptions,enter these additional descriptions be pre-printed. _ 1 in Item 27 on the Continuation Sheet(EPA Form 8700-22A).-Also,if more than one II Emergency Response phone number applies to the various wastes described in either Item 9b '.or Item 27,enter applicable Emergency Response phone numbers immediately following the shipping descriptions for those Items. Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST jtt [' f, # � a�:� ,j p 0 0 3-q 5 JJ K ! 5.Generators Name and Mailing Address T%N OF BARNSI'f"3Pd..E Generators Site Address(if different than mailing address) P-130 HAIN STREET )•il:-N-TH DIVISION N 1189 K1110IFY'S LANE II Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number CLEM VENTURE, INC. 7.Transporter 2 Company Name U.S.EPA ID Number i 8.Designated Facility Name and Site Address cknoral Chemical Cf'lrp. U.S.EPA ID Number i 1.33 Lee and Street II Framingham, MA 01701 j Facilitys Phone: (0508) 872-W,130 pi6 an 1;9,71079 ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit p HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes Ii % t. rite Corrosive liquid, acidic, inergani.c, Q o nos. R UN3264 P9 11 M902) f z A 2.Waste C 7f-MU C ai k',Al i l i uifii, n-o-%.. 8 (14171*� Woe g ' 3.141*A-"E KRUVIE0 OILY SOLIDS 4"1AO 1 4• w R • i 4 ' 14.Special Handling Instructions and Additional Information 9t02-'''.110/801 Olt I i 55i"52O f«t60 (T)LF(ty(tM-6 ACID LAD PACK (Z)LP -9-5 AL,4-A.11RE LAB PAM MIOIS-2 OILY ISOLIVS, 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, i marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. G}enneratoes/Offerors Printedrryped fN[�ame• rt {_ Signature., { r Month Davy Year f;_...•.d!+.•.,a ! R`}'1 �. "' "d ''4'4' , �+�. fk. .Y `' �) % fay C.�•i�,... ,•,k-i J 116.International Shipments F C ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: l W 17.Transporter Acknowledgment of Receipt of Materials r Ej Transporter�,l Printedrryped�Name Signature "q w;r Month Day Year QTransporter 2 Print drryped Name Signature Month Day Year ~ I 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: I 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q � z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a I Printed[Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3605) Previous editions are obsolete. GENERATOR'S INITIAL COPY s U.S.EPA Form 8700-22 Item 10.Containers(Numberand Type) Read all instructions before completing this form.- _ _Enter the number of containers for each waste and the appropriate abbreviation from Table I 1. This form has been designed for use on a 12-pitch(elite)typewriter which is also compatible (below)for the type of container. with Standard computer printers;a firm point pen may also be used-press down hard. TABLE I:-TYPES OF CONTAINERS 2. Federal regulations require generators and transporters of hazardous waste and owners or - BA=Burlap,cloth,paper,or plastic bags. DT=Dump truck. operators of hazardous waste treatment,storage,and disposal facilities to complete this form CF=Fiber or plastic boxes,cartons,cases. DW=Wooden drums,barrels,kegs. (EPA Form 8700-22)and,if necessary,the continuation sheet(EPA Form 8700-22A)for CM=Metal boxes,cartons,cases(including HG=Hopper or gondola cars. v both inter-and intrastate transportation of hazardous waste. I roll-offs). = Public reporting burden for this collection of information is estimated to average: 30 minutes for generalors,'10 `CY CW Wooden boxes,cartons,cases. TC=Tank cars. =Cylinders. - TP=Portable tanks. minutes for transporters,and 25 minutes for owners or operators of treatment,storage,and disposal facilities. This DF=Fiberboard or plastic drums,barrels,kegs. TT=Cargo tanks(tank trucks). includes time for reviewing instructions,gathering data,completing,reviewing and transmitting the form. Any DM=Metal drums,barrels,kegs. correspondence regarding the PRA burden statement for the manifest must be sent to the Director of the Collection Strategies Division in EPA's Office of Information Collection at the following address: U.S.Environmental Item 11.Total Quantity Protection Agency(2822T);1200 Pennsylvania Ave.;NW.,Washington,DC 20460-Do not send-- -- - Enter,in designated boxes,the total quantity of waste.'Round partial units to the nearest r the completed form to this address. whole Unit,and do not enter decimals or fractions. To the extent practical,report quantities using appropriate units of measure that will allow you to report quantities with precision. I.Instructions for Generators Waste quantities entered should be based on actual measurements or reasonably accurate Item4.Generator's U.S.EPA Identification Number estimates of actual quantities shipped. Container capacities are not acceptable as estimates. Enter the generator's U.S.EPA twelve digit identification number,or the State generator - -Item 12.Units of Measure(WeighWolume) identification number if the generator site does not have an EPA identification number. Enter,in designated boxes,the appropriate abbreviation from Table II(below)for the unit of s. Item 2.Page.1 of_„ measure. Enter the total number of pages used to complete this Manifest(i.e.;the first page(EPA Form TABLE II.--UNITS OF MEASURE 8700-22)plus the number of Continuation Sheets(EPA Form 8700-22A),if any). G=Gallons(liquids only). N=Cubic Meters. Item 3.Emergency Response Phone Number K=Kilograms. P=Pounds. Enter a phone number fo7 which emergency response information can be obtained'in the event L=Liters(liquids only). T=Tons'(2000 Pounds). of an incident during transportation. The emergency response phone number must: M=Metric Tons(1000 kilograms). Y=Cubic Yards. 1. Be the number of the generator or the number of an agency or organization who is capable Note: Tons,Metric Tons,Cubic Meters,and Cubic Yards should only be reported in of and accepts responsibility for providing detailed information about the shipment; _ connection with very large bulk shipments,such as rail cars,tank trucks,or barges. 2. Reach a phone that is monitored 24 hours a day at all times the waste is in transportation Item 13.Waste Codes (including transportation related storage);and 3. Reach someone who is either knowledgeable of the hazardous waste being shipped and Enter to six federal and state waste codes to describe each waste stream identified in Item 9b. State waste codes that are not redundant with federal codes must be entered here,in has comprehensive emergency response and spill cleanup/incident mitigation information addition to the federal waste codes which are most representative of the properties of the for the material being shipped or has immediate access to a person who has that knowledge waste. and information about the shipment. , Note: Emergency Response phone number.information should only be entered in Item 3 when Item 14.Special Handling Instructions and Additional Information there is one phone number that applies to all the waste materials described in Item 9b. If a 1. Generators may enter any special handling or shipment-specific information necessary for situation(e.g.,consolidated shipments)arises where more than one Emergency Response the proper management or tracking of the materials under the generator's or other phone number applies to the various wastes listed on the manifest,the phone numbers handler's business processes,such as waste profile numbers,container codes,bar codes, associated with each specific material should be entered after its description in Item 9b. or response guide numbers. Generators also may use this space to enter additional Item 4.Manifest Tracking Number _ descriptive information about their shipped materials,such as chemical names,constituent percentages,physical state,or specific gravity of wastes identified with volume units'in This unique tracking number must be pre-printed on the manifest by the forms printer.. Item 12. Item 5.Generator's Mailing Address,Phone Number and Site Address 2. This space may be used to record limited types of federally required information for which Enter the name of the generator,the mailing address to which the completed manifest signed there is no specific space provided on the manifest,including any alternate facility by the designated facility should be mailed,and the generator's telephone number. Note,'the designations;the manifest tracking number of the original manifest for rejected wastes and telephone number(including area code)should be the normal business number for the residues that are re-shipped under a second manifest;and the specification of PCB waste generator,or the number where the generator or his authorized agent may be reached to -descriptions and PCB out-of-service dates required under 40 CFR 761.207. Generators, provide instructions in the event the designated and/or alternate(if any)facility rejects some or -, however,cannot be required to enter information in this space to meet state regulatory all of the shipment. Also enter the physical site address from which the shipment originates requirements. only if this address is different than the mailing address. Item 15.Generatoes/Offeroes Certifications Item 6.Transporter 1 Company Name,and U.S.EPA ID Number 1. The generator must read,sign,and date the waste minimization certification statement. In Enter the company name and U.S.EPA ID number of the first transporter who will transport the signing the waste minimization certification statement,those generators who have not waste. Vehicle or driver information may not be entered here. _ been exempted by statute or regulation from the duty to make a waste minimization Item 7.Transporter 2 Company Name and U.S.EPA ID Number certification under section 3002(b)of RCRA are also certifying that they have complied If applicable,enter the company name and U.S.EPA ID number of the second transporter who_ with the waste minimization requirements. The Generator's Certification also contains the will transport the waste. Vehicle or driver information may not be entered here. required attestation that the shipment has been properly prepared and is in proper If more than two transporters are needed,use a Continuation Sheet(s)(EPA Form 8700 22A). condition for transportation(the shipper's certification). The content of the shipper's certification statement is as follows:."I hereby declare that the contents of this Item 8.Designated Facility Name,Site Address,and U.S.EPA ID Number consignment are fully and accurately described above by the proper shipping name;and Enter the company name and site address of the facility designated to receive the waste listed are classified,packaged,marked and labeled/placarded,and are in all respects in proper on this manifest. Also enter the facility's phone number and the U.S.EPA twelve digit -- - -condition for transport according to applicable international and national governmental identification number of the facility. regulations. If export shipment and I am the Primary Exporter,I certify that the contents of Item 9.U.S.DOT Description(Including Proper Shipping Name,Hazard Class or Division, this consignment conform to the terms of the attached EPA Acknowledgment of Consent." Identification Number,and Packing Group) When a party other than the generator prepares the shipment for transportation,this party Item 9a. If the wastes identified in Item 9b consist of both hazardous and nonhazardous may also sign the shipper's certification statement as the'offeror of the shipment. materials,then identify the hazardous materials by entering an"X"in this Item next to the 2. Generator or Offeror personnel may preprint the words,"On behalf of in the signature corresponding hazardous material identified in Item 9b. - : --block or may hand write this statement in the signature block prior to signing the Item 9b. Enter the U.S.DOT Proper Shipping Name,Hazard Class or Division,Identification generator/offeror certification,to indicate that the individual signs as the employee or agent Number(UN/NA)and Packing Group for each waste as identified in 49 CFR 172. Include of the named principal. technical name(s)and reportable quantity references,if applicable. Note: All of the above information except the handwritten signature required in Item 15 may If additional space is needed for waste descriptions,enter these additional descriptions - be pre-printed.- Note: in Item 27 on the Continuation Sheet(EPA Form 8700-22A). Also,if more than one `` - Emergency Response phone number applies to the various wastes described in either Item 91D or Item 27,enter applicable Emergency Response phone numbers immediately following the shipping descriptions for those Items. " Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 2.7Page 1 of 3.Emergency Response Phone ous 1.Generator ID Number 4.Manifest Tracking Number UNIFORM HAZARD WASTE MANIFEST 14P50M524645 1 0-09) 872-WJ01 000896394 JJK 5.Generator's Name and Mailing Address TOWN OF BARNS TAKE Generator's Site Address(if different than mailing address) 2010 MAYN STREET HFAt-TH NVISION 11139 FUDMY'S LANE BARN13-TABLE, MA M6101 BARMTAKE, HA Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number CLEAN VENTURE. INC. Nionmr, 193 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address SWETV--VLFXN SYSTEMS, INC., U.S.EPA ID Number 1200 SYLVAN STREEFT LINMN, WJ 0-10.46 Facility's Phone: (9M) 862-20M N31DOORMI 91,11 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 1-RGI, Waste Ftammable liquids., ri.LN.s. 3 UN1993 D001 D018 0__ 9 28 L 2. 3. 4. 14.Special Handling Instructions and Additional Information 8(4 ,/�361:�4 0)1K 6AWL1NFA4ATC p -1 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature,,N Month Day Year TJ 16.International Shipments [:]Import t.U.S. ❑Export from U.S Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials 1 Transporter 1,Printedrryped Name Signature 41 Month Day Year W 0 t U) j I- IL Z Transpode(-2 Printed/Typed Name Signature 'IN-- Mcirth Tay t%rr 18.Discrepancy 18a.Discrepancy Indication Spare El Quantity 1:1 Type El Residue El Partial Rejection El Ful!Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number LL Facility's Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year !R Z .2 I 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) U) UJ I 2. T T 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted H Item 18a Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY U.S.EPA Form 8700-22 Item 10.Containers(Number and Type) Read all instructions before completing this form. _ _Enter the number of containers for each waste and the appropriate abbreviation from Table I 1: This form has been designed for use on a 12-pitch(elite)typewriter which is also compatible (below)for the type of container. r. with standard computer printers;a firm point,pen may also be used-press down hard. TABLE I.--TYPES OF CONTAINERS - 2. Federal regulations require generators and transporters of hazardous waste and owners or BA=Burlap,cloth,paper,or plastic bags. DT=Dump truck. operators of hazardous waste treatment,storage,and disposal facilities to complete this form CF=Fiber or plastic boxes,cartons,cases. DIN=Wooden drums,barrels,kegs. (EPA Form 8700-22)and,if necessary,the continuation sheet(EPA Form 8700-22A)for CM=Metal boxes,cartons,cases(including HG=Hopper or gondola cars. + both inter-and intrastate transportation of hazardous waste. roll-offs). CW=Wooden boxes,cartons,cases. TC=Tank cars. Public reporting burden for this collection of information is estimated to average: 30 minutes for generators,10 CY=Cylinders. TP=Portable tanks. ' minutes for transporters,and 25 minutes for owners or operators of treatment,storage,and disposal facilities. This ' DF=Fiberboard or plastic drums,barrels,kegs. TT=Cargo tanks(tank trucks). includes time for reviewing instructions,gathering data;completing,reviewing and transmitting the form. Any DM=Metal drums,barrels,kegs. correspondence regarding the PRA burden statement for the manifest must be sent to the Director of the Collection Strategies Division in EPA's Office of Information Collection at the following address: U.S.Environmental Item 11.Total Quantity 1 Protection Agency(2822T);1200 Pennsylvania Ave.,NW.,Washington,DC 20460. Do not send Enter,in designated boxes;the total quantity of waste. Round partial units to the nearest the completed form to this address. whole unit,and do not enter decimals or fractions. To the extent practical,report quantities using appropriate units of measure that will allow you to report quantities with precision: I.Instructions for Generators Waste quantities entered should be based on actual measurements or reasonably accurate Item 1.Generator's U.S.EPA Identification Number estimates of actual quantities shipped. Container capacities are not acceptable as estimates. Enter the generator's U.S.EPA twelve digit identification number,or the State generator Item 12.Units of Measure(WeighWolume) - identification number if the generator site does not have an EPA identification number. Enter,in designated boxes,the appropriate abbreviation from Table II(below)for the unit of Item 2.Page 1 of _ t -measure. Enter the total number of pages used to complete this Manifest(i.e.,the first page(EPA Form TABLE 11.--UNITS OF MEASURE 8700-22)plus the number of Continuation Sheets(EPA Form 8700-22A),if any). G=Gallons(liquids only). N=Cubic Meters. Item 3.Emergency Response Phone Number K=Kilograms. P=Pounds. t Enter a phone number for which erergency response information can be obtained in the event k- L--Liters(liquids only)'- - `T=Tons(2000 Pounds). of an incident during transportation. The emergency response phone number must: M=Metric Tons(1000 kilograms). Y=Cubic Yards. ' 1. Be the number of the generator or the number of an agency or organization who is capable Note: Tons,Metric Tons,Cubic Meters,and Cubic Yards should only be reported in _of and accepts responsibility for providing detailed information about the shipment; connection with very large bulk shipments,such as rail cars;tank trucks,or barges. 2. Reach a phone that is monitored 24 hours a day at all times the waste is in transportation Item 13.Waste Codes (including transportation related storage);and Enter up to six federal and state waste codes to describe each waste stream identified in Item 3. Reach someone who is either knowledgeable of the hazardous waste being shipped and has comprehensive emergency response'and`spill cleanup/incident mitigation information - 9b..State waste codes that are not redundant with federal codes must be entered here,in for the material being shipped or has immediate access to a person who has that knowledge addition to the federal waste codes which are most representative of the properties of the and information about the shipment. i waste. Note: Emergency Response phone number,information should only be entered in Item 3 when _Item 14.Special Handling Instructions and Additional Information there is one phone number that applies to all the waste materials described in Item 9b. If a 1.-Generators may enter any special handling or shipment-specific information necessary for situation(e.g.,consolidated shipments)arises where more than one Emergency Response the proper management or tracking of the materials under the generator's or other phone number applies to the various wastes listed on the manifest,the phone numbers handler's business processes,such as waste profile numbers,container codes,bar codes, associated with each specific material should be entered after its description in Item 9b. or response guide numbers. Generators also may use this space to enter additional Item4.Manifest Tracking Number _ .. descriptive information about their shipped materials,such as chemical names,constituent percentages,physical state_,or.specific gravity.of wastes identified with volume units in This unique tracking number must be pre-printed on the manifest by the forms printe(. Item 12. Item 5.Generator's Mailing Address,Phone Number and Site Address 2. This space may be used to record limited types of federally required information for which Enter the name of the generator,the mailing address to which the completed manifest signed there is no specific space provided on the manifest,including any alternate facility . by the designated facility should be mailed,and the generator's telephone number. Note,the designations;the manifest tracking number of the original manifest for rejected wastes and telephone number(including area code)should be the normal business number for the residues that are re-shipped under a second manifest;and the specification of PCB waste generator,or the number where the generator or his authorized agent may be reached to ; descriptions and PCB out-of-service dates required under 40 CFR 761.207. Generators, provide instructions in the event the designated and/or alternate(if any)facility rejects some or however,cannot be required to enter information in this space to meet state regulatory all of the shipment. Also enter the physical site address from which the shipment originates requirements. only if this address is different than the mailing address. V Item 15.Generatoes/Offeror's Certifications _ Item 6.Transporter 1'Company Name,and U.S.EPA ID Number _ 1.'The generator must read,sign,and date the waste minimization certification statement. In Enter the company name and U.S.EPA ID number of the first transporter who will transport the signing the waste minimization certification statement,those generators who have not waste.'-Vehicle or driver information may not be entered here._ _. _ been exempted by statute or regulation from the duty to make a waste minimization Item 7.Transporter 2 Company Name and U.S.EPA ID Number certification under section 3002(b)of RCRA are also certifying that they have complied If applicable,enter the company name and U.S.EPA ID number of the second transporter who With the waste minimization requirements. The Generator's Certification also contains the will transport the waste. Vehicle or driver information may not be entered here. required attestation that the shipment has been properly prepared and is in proper If more than two transporters are needed,use a Continuation Sheet(s)(EPA Form 8700 22A). 'condition for transportation(the shipper's certification).-The content of the shipper's certification statement is as follows: "I hereby declare that the contents of this Item 8.Designated Facility Name,Site Address,and U.S.EPA ID Number consignment are fully and accurately described above by the proper shipping name,and Enter the company name and site address of the facility designated to receive the waste listed are classified,packaged,marked and labeled/placarded,and are in all respects in proper on this manifest. Also enter the facility's phone number and the U.S.EPA twelve digit 4 condition for transport according to applicable international and national governmental identification number of the facility. regulations. If export shipment and I am the Primary Exporter,I certify that the contents of Item 9.U.S.DOT Description(Including Proper Shipping Name,Hazard Class or Division, this consignment conform to the terms of the attached EPA Acknowledgment of Consent." Identification Number,and Packing Group) _ When a party other than the generator prepares the shipment for transportation,this party Item 9a. If the wastes identified in Item 9b consist of both hazardous and nonhazardous may also sign the shipper's certification statement as the offeror of the shipment. materials,then identify the hazardous materials by entering an"X"in this Item next to the 2. Generator or Offeror personnel may preprint the words,"On behalf of in the signature corresponding hazardous material identified in Item 9b. - - - -block or may handwrite this statement in the signature block prior to signing the Item 9b.•Enter the U.S.DOT Proper Shipping Name,Hazard Class or Division,Identification generator/offeror certification,to indicate that the individual signs as the employee or agent t Number(UN/NA)and Packing Group for each waste as identified in 49 CFR 172. Include of the named principal. technical name(s)and reportable quantity references,if applicable. Note: All of the above information except the handwritten signature required in Item 15 may Note: If additional space is needed for waste descriptions,enter these additional descriptions be pre printed'. in Item 27 on the Continuation Sheet(EPA Form 8700-22A). Also,if more than one e Emergency Response phone number applies to the various wastes described in either Item 9b t or Item 27,enter applicable Emergency Response phone numbers immediately following the shipping descriptions for those Items. TOWN OF BARNSTABLY(see PLIANCE: CLASS: 1.Marine,Gas Stations,Repair satisfactory 2. Printers BOARD OF HEALTH ry 3.Auto Body Shops nsatisfactory- 4.Manufacturers COMPANY/1/� � 9 � "Orders") 5.Retail Stores 6.Fuel Suppliers ADDRESS �ll/1�,�,�1/ ,� Class: 7.Miscellaneous QUANTITIES AND STORAGE (IN= indoors;OUT=outdoors) MAJOR MATERIALS IN OUT IN JOUT IN OUT #&gallons Age Test Fuels: Gasoline Jet Fuel (A) Diesel, Kerosene, #2 (B) Heavy Oils: waste motor oil (C) 5Vx new motor oil(C) transmission/hydraulic Synthetic Organics: degreasers Miscellaneous: p �✓L� ' a` 0-lie CAW ' DISP SAURECLAMATION REMARKS: 1. Sanitary Sewage 2.Water Supply - � ``� —� 0011, O Town Sewer Public /On-site OPrivate 3. Indoor Floor Drains YES____NO O Holding tank:MDC O Catch basin/Dry well O On-site system 4. Outdoor Surface drains:YES./NO ORDERS: O Holding tank:MDC �Catch basin/Dry well f On-site system 5.Waste Transporter YES NO 1. .- 2. Person(s) Interviewed In pector Da+10 J: A / e S State of New Jersey �9 P Department of gnvironm'i ntal Prot ction IIIIIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIII Hazardous Waste Regulation Programme 5281848 Manifest Section P.O. Box 414, Trenton, NJ 48625-0414 Please type or print in block letter . Form designed for use on elite(12-pitch)typewriter.).,. . Form Approved. OMB No.2050-0039. 1.Generator's US EPA ID No. Manifest 2.Page 1 UNIFORM HAZAR OUS Information in the shaded areas Document No. WASTE MANIFEST . rt g. { 4 of is not required by Federal law. 3. Generator's Name and Mailing Address A.State Manifest Document Number T009 0&' bAtA-ATAAi.E YZL lnfl IV*, :OR NJA 5281848 rlrpV r VA ' B.State Generator's ID-(Gen.Site Address) 4. Generator's Phone 5: Transporter 1 Company Name 6. US EPA ID Number C.State Trans.ID=NJDEP CLEAN .'� 1 1 �4r IX I I"tIt 1 S # n 1 17 1:k Ii Decal No.- N 7. Transporter 2 Company Name 8. US EPA ID Number D.Transporter's Phone - I` E.State Trans.ID-NJDEP 04 0) 9. Designated Facility Name and Site Address 10. US EPA ID Number Decal'No.- o> F.Transporter's Phone( ) 17 tv011T�+114 t;y.�t T bi'�eCtr '� G.State Facility's ID ✓i~A.a Fwd4i}.�L 4�. Lai i 47,f f 4 - .. , , x1 Cr •t. - ' n ^� Is. f H.Facility's Phone c 11. US DOT Description(including Proper Shipping Name,Hazard Class or Division, 12.Containers 13: 14. w P ( 9 P PP 9 I. o /D Number and Packing Group) Total Unit Waste No. m HM No. Type Quantity WWoI c a. b. ")0 e", E E R w A C. 0 0 n. R ai d. z L J. Additional Descriptions for Materials Listed Above K.Handling Codes for Wastes Listed Above ISD� a. - o #tCl b. , <. f d. b d (D 15. Special Handling Instructions and Additional Information r rn tta+µfl ftti� 1sr,.' i> 2: :i E m r r• d`�i is3t I:i�.��' Svc �•I� .� t;z� C"X 'T 1.6.GENERATOR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are .- y classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national:government r regulations. . If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present 5 and future threat to human health and the environment; OR, if I am a small quantity generator, i have made a good faith effort to minimize my waste generatiori 1i and select the best waste management method that is available to me and that I can afford. Printedrryped Name Signature Month Day Year N T 17.Transporter 1 Acknowledgement of Receipt of Materials A Printed/Typed Name Signatured'G' Month Day Year 2) p 18.Transporter 2 Acknowledgement of Receipt of Materials a) T Printed/Typed Name Signature n y Year c E R 0 19.Discrepancy Indication Space ai 0 m F c C W I 1 L I 20.Facility-Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. T Printed/Typed Name S Month Day Year 00 Y ignature EPA Form 8700-22 SIGNATURE AND INFORMATION MUST BE LEGIBLE ON ALL COPIES 6—GENERATOR MAIL TO-TSD'S STATE + tat i i11t, ,• c 1 !*' 'fy ikkyy 'G ERAL IN pgMATION " x l !rx r�.17t. r Itein'13' 3 fcFrALV4 QUANTITY-Enter !th total t' of wastes descri d on each line. 84 r� ewe• .� '"'.'"" -,I,t r .r* y� ' .. ,y a DON 4 CTION$: ' The Hazardous Waste meiufe t lsri�eSigned to track wsafe from the pomtof°geet��ration to final dtspo§al' Item 14: UNIT(Wt.Nol:rEnterytha,�'ppfopriate,at?brgg aeon from Table 11(bR)ow)for the unit of (cradle to grave).In order to accomplish this goal,it is essential that all items on the manifest be cent :*.r+ty measure used in.determirN the.iotal quardity of waste described on each line. plated correctly.Incomplete,incorrect or Illegible manifests are violations gf the law iarA could mak6 IT r i u I r you subject to civil or criminal liabilities as specified In the New Jersey Hazardous Waste Regblations J c READ AEL IF1STRlCT-INSTRUCTIOIONSI EOOROMPLETING "' 'r..•� �u �TABLFJP ! :, _ .P ,�G s ri r t , f .c:I r1 r #i"�, "f£ ^'f, ,,A t• 40, :32 n ram..,.. .,�.. _ . ,rum._ .r: x r ,. TS 0P'!" 7QSVR _ a IT� ti, O u r G-Gallons(liquids only) _ + State .¢,✓,Federal regt{latfons_require_Generetorss,Trar pgltg[s,, 'ndr{jreatment, Storage_&-Oisposal„1.- _ ¢ P Pounds 1 �-+ ,r r Facilities(TSDFs)to use this form+and if necessary the continuation sheet for both inter-and intrastate T=Tons"(2000 bs E - { shipments.Continuation sheets lqay'burchaso',ortlrnercially and photocopied to provide copies as Y-Cubic yards r_,p described below. '-',ti'` r r 3 �. X 5_+l1„�Yu_ _` L-Liters(liquids or4) ` K-Kilograms The New-Jersey manifast contains S copies,,,ALL COPIESsj MUST BE LEGIBLE. This form M-Metric Tons(1000 kg) is designed for use on a 12 pitch (elite) typewriter; a firm pall point pen may also be used N-Cubic Meters + only If you press down HARD.The 0 copies must be filed with the appropriate party as they are completed. f COPY DISTRIBUTION is a"s fllows` '' " ' r - +•, Item•15:..e-.__-SPECIALMANDLiNG INSTRUCTIONS AND ADLt1 6NAL INFORMAT?OtJ-J ^ p d f) Use this space to indicate special tmnsportatienfitreatrhemt"storage, disposal,for Bill of ORIGINAL:. �:DESTINATION_STATE-TSIM .must_m9il.ibrigin to the state regulatory 'agency Lading information, if any. If an alternate facility is desgnated, note,it Here. For where the facility is located. t t 1 ; INTERNATIONAL SHIPMENTS,generators must enter the point of departure(city& COPY-2: j GENERagencyA here the warms a was ganerated TSOF .ls :this-copy-.bade to the state:reg4latory )-.- - - state)in this sppace.'fhis space may also be used for"emeigsricy-r8sponsQ" j F COPY 3r-- GENERATOR COPY Ttie TSflF marls-this copy back to the generator of the telephone numbers,and any other information the generator is required to include west®. t t s., 11 ! { n about the shipment in accordance with 49 CFR Part 172,Subpart G as app!iga Id for F- � i. , -«-- 1--�- --RCRAzhazardous•waste•and VSDCT hazardous materials.--- 1' "' T§DF'COPY-TSDF Reeps'fhis copy for his ieoSrds. ! lY,t�,.s'r l-<t, � i W - � •' COPY 5:_ TRANSPORTER COPY-The transportekkeeps flits copy for his records. Item 16: GENERATOR'S CERTIRUAT16N-TheYG6neraior most tead,'sign(byr{(a'nd)and date the eertifX NOTE: If ,a continuing. transporter is used 'the generator is responsible for cation.This must be done the day the transporter picks up the waste shipment(date of receipt by supplying•--him with in legible photocopy,- which must contain required transporter).If a mode other than highway is used,the word'highway'should be fined oat and the t appropriate mode(rail,water,air}inserted in the space.if another mode in addition to the highway signatures. % c CdPY 6:- DESTINATION' STATE-The a mode is used,enter the appropriate additional mode(e.g.'and rail`)in this space. i ggtefgtar mails tilts copy to I the state. regulatory V ltem'A: STATE MANIFEST DOCUMENT NUMBER -Number preprinted by New Jersey?xcept on the .,agency where the designated facility MDF)is located...t 4 L-.1,, 1._L.-'s. ,- L.'-_ -continuation-streets:Enterlhis'numberon-each continuation sheet attached to'a manifest COPY 7: GENERATOR! STATE-The generator mails 'this i copy.-to {the state regulatory,,,,.'V4+em B:'t °1BTATE GEN 10=he State Gemeralor I&it the sltreet address df ire wastelgeneration site.if the t,,agency where the waste was generated. I ( mailing address'arod the site address'are the same,enter"same*. CQPV 8: ✓GENERATOR COPY-the yeneratof keeps this copy too his records. _ _ _. __-Iteo].G:_ STATE.TRANRI JR Enter U.New Jersey state pen t number.This rpust include both the trans- _ ALL 8 COPIES MUST BE LEGIBLE porters permit number and the decal number of the hazardous waste transport uniti or hazardous MANIFEST FORM ACQUISITION waste vehicle which contains the waste.For rail shipment(s)enter the alpha numeric I.i3.number I I assigned to the railcar in lieu of the decal number. 1.! If the destination (consignment) state supplies a manifest requires its use, then the Item D: TRANSPORTER PHONE-Enter a telephone number with area code where an autho}ized agent of generator is obligated to,obtain the manifest from that states 1 the transporter can be reached. 2. If ilia destination state does not supply the"ma'gifest,-6ui`the generator state does;then Item E: �-STATE TRAN ff2ID If a ppt'cabie,enter the New Jersey State permit number of the waste carrying the generator is obligated to obtain the manifest forth from the nerator state. portion of the second vehicle. 3. If neither the generator state or the consignment slat supplies the manifest, then•the Item F: TRANSPORTER PHONE-1 applicable,enter a telephone number with area code where an author- generator may obtain the manifest from any source. ized agent of the second transporter may be reached. I (!r ' ! t ) Item G:,, STATE FACILITY'S ID-No entry is required by New Jassy. r _a_• _ GEj`lERATOR.SECTION_ _f -ItemR -•FACILITY•PHONE-Enter a-telephone number with.atea code of the-TSDF designated to receive Item 1: GENERATOR'S EPA 11)N0:MANIFEST DOCUMENT NO.-Enter the me '� the waste listed on the manifest , r I generators EPA identification number.The manifest document number is a unique Item I: WASTE NO.-Enter the 4-dV hazardous waste number as it appears in N.J.A.C.7:26G•51 at.sea Sdigit number the generator assigns to each manifest,for his reoordkeeping purposes. (For example'K047'is the waste number designated for pinktred water from TNT operations.)The 1 Use of.serially increayring numbers je.gt 00((01,00002,ek.)is recommended. proper waste number that accurately describes the shipment,shall be determ ad according to the Item 2: .-_ .PAGER Af -Griterthetotal numberoVpsges.used to completathis manifast;- -___ .,—_v -_h16raTctlyatN.J.A.C.'7:26G4i.2-- r-" - --- • t -1 t I i.e.the first page pluslthe number of continuation sheets,if any. Item J: ADDITIONAL DESCRIPTIONS FOR MATERIALS LISTED ABOVE-Enter desgdption of analysis for Item 3: GENERATOR'S NAME&MAILING ADDRESS-Enter the name(as notified to any waste which does not have a complete USDOT shipping description or has an n.o�sf EPA)&mailing address of the generator.The addre should be the location `- designation.Enter a general description of the waste stream.(i.e.groundwater contaminated r that will manage the returned manifest aorm§. , + r ! with creosote and copper sulfate).Additionally,for any n.o.s.entry in Item 11 which does not conform Item 4: ,_ GENERATOR'S PHONE NUMBER 1 titer a telephone nanbet with area code __ ----to the requirementsst-49 CFR 172.203(K)enter the two components;apd their percenta§es, s J.whare an authorized, of thro generator can be reached in an emergency. which most predorfiiriahty contribute to the hazards�of the mixture or solution.Enter the physical Item 5: TRANSPORTER 1 COMPANY NAME-Enter the corriPany name(as state(S Solid,L=Liquid,G=Gas,SL=Sludge)EPA hazard codes(1=Ignitable,C=Corrosive notified to EPA) B the first transporter who will transport the waste. R=Reagive,E=TCLP,H=Acute.Hazardous,T=Toxic).Enter additional information)as required Item 6: ; US EPA ID NUMBER-Enter the EPA identification number of the first by thawasts code hierarchy at N.J.AC.7:26•G-6.2. 1 1 transporter identified in item 5;. _ _ ,, - _-- .._._o--�.. .. Item 7: TRANSPORTER 2 COMPANY NAME-If applicable,enter the company name TRANSPORI�ER�SECTION� c ' (as notified to EPA)of the second transporter who will transport the waste, u r It is a vitiation by the transporter if he accepts hazardous waste from a generator who fails to properly complete the if more than two(2)transporters will be used,use a pontinuation sheet and manifest transports waste to an unauthorized I aS.;ty,pridtor fads to obtain the date and handwritten signature of tlje �+ -list the transporters in`the ordeithey will be transporting the waste:,—-^ -^' next!iaulei ownerlopeiator of th ra $1� clGy oq t rrlanSfesl' Item 8: US EPA ID NUMBER-If a second transporter is used,enter the EPA - �'• - ° �' ' ' { identification number of the second transporter identified in item 7. Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting die Item 9: DESIGNATED FACILITY NAME&SITE ADDRESS-Enter the company name waste on behalf of the first transporter.That person must acknowledge acceptance of the 3 and site address(as notified to the EPA)of the treatment,storage,or disposal waste described on the manifest by signing and eperng the date of receipt. i ' facility(TSDF)designated to receive the waste listed on this manifest.The Item 18'. TRANSPORTER 2 ACKNOWLEDGEMENT-If apftable,follow instructions for Item 17 for the address must be the site address,which may differ from the mailing address. second transporter. Item 16,c'-,EPA ID'NUMI§ER-Entei the EPAjdentifkationW7"w-er'f,thedesignated,TSDl t, ,n :,,��NO. 'xh -ALL'HAZA.RDOUS;WA$7E'.TF NSFr�}RfER 13PERAT{NG 1{C'NEW JEf�SEYaMUSTfHAVE_A (prwaste reuse facility)Asted in item;9. 4. VALID NSW JERSEY HAZARDOUS{�1ASTE RANSPQRTER`S PERMIT, , „ ..T h.••�. C.1tr,,r.x^ ,,. •v., ."'-.j d--- 11 a Item 11: USDOT DESCRIPTION-Enter the correct USDOT'shipping name,hazard class t or division,the identification number and the packing group(49 CFR 172.202). DESIGNATED FACILITY(TSDF)SECTI8N i I r„The word waste must,appear as part of,the USDOT shipping name it the.wasta;,Jj .i�,lt item 19: z ••,OISCREPANCY INDICATION:SPACE=Yhe authgdzed representative of the designated facility must Is a fadetai.RCRA•hazardous waste(49 CFR•17�t'101).;Fora waste with aj,. y,t,t�,g,•,,i1 „ �„A a 7n;this.spafe any signfieanGrksgrepeocy behve8n:the waste described on the manifest and j n.o.s.designation enter ilia lnfortnatipri,as required by 49rbFR�{72. 03.Enter _i J ,q._ a u s• , , t1 ,wag e,acq{�l. ervgd it the fi. ig.,Arty j%'wed`)materials sfould 4 fisted heoe,�along �- 'acl&tfonal shlpping clescriptiori information as required fly 49 CFIi 17 Subpart` hvlfli an'9>t anefi of'(he d�{fbsNoA of th3 rejekted wastes..Owners a)td'i9perators;of facilities - - ...--.C.If more..than 4 wastes are beingshipped,_a.second manifest or.continuation t`.rr r t,r„'r'1 t T9r �5•.I��it agtJtctlzE(t,S*EiS die;;}mpsi;:Std�as`3hat mcetveit auth6il�aUon.firm the U.S.EPA ' .�,yr to administer the hazardous waste r ram V_ sheets should be used.For information on USDOT waste descriptions call your l p og )should conta4t the✓,State-agency forrformation on USDOT regio al office. State.Discrepancy Report requirements: ' Item 12: CONTAINER(NO.&TYPE)-Enter the number of containers for each waste �_. It�•em220: FACILITY OWNERIOPERATOR CERTIFICATION-Print or type the name of the perlgn receiving .` and t ie appropriaCe abbre`viafions Trout Table f(beto'w)'for the type of container - the-wasteoribehalf of the owner/c4wator-of the designated TSDF.That peteon-mustabknowledge .Used: _ _ _ -_ _ receivimj:the w {e deer.✓bo<t ifas uh tbdnterttby,signing and entering thadate of receipt. ItemIt- HANDLING,CODES-TSDF•SHMf)-COMKEiE-Enter-thevitimate harrdling-method'utilized at r ' the designated facility for each waste.Only the fo'.!owing process Codes may ife used:Storage--Wl TABLE 1 (container);S02(Tank);SO4(Surface Impoundment);S05(Other-specify) Treatment=T01 `I t CONTAINER TYPES �� µ �(Tank T02'Surface ITEwndment;T03(Incinerator);T04 Other-s i ),Dis sakD79 �—i ( ) ( Pec PoDM-Milltal drums barrels,kegs d 1 g� l) (�4hr Application);D92(OceanDisposal);D$$i 1 urfaceirrt2h1. �. DVIG�Voofjem,drums barrels,-kegs-y. -.._ ._� _ -. -.(�.w hipWn_.w�. P 15) c v a a t jj r OTE For interstate shipments you may be required to comply with the manifesUmg tagwrements of both DF-FitWrbbaFd?or plastic drums,berets,kegs 0 . the corulgnrnerit and generator states regarding the completion oY'specitic Infommaton Included TP-Tanks portable in lettered hems A-K. Please check with both generator and consignment states'for specif s C-TT-aarrkoca tanks(Tank trucks) _y�_ . _ A �. _ i_ __requirements..New.Jefsay requires that all.information be filledin-except for Item,.•G"•_. DT-Dump truck ±•! CY-Cylinders I d4 Public reporting burden for collection of information is estimated to average:37 minutes for generators,t5 minutes t.yo�t CM-Metal boxes,cartons,cases(including roll-offs) P g g ' nr•'t!I for transporters,and 10 minutes for treatment,storage and disposal facilities.This includes time for reviewing CW-Wooden boxes,cartons,cases instructions,gathering data,and completing and reviewing the form.Send comments regarding the burden CF-Flber or plastic boxes,cartons,cases estimates including suggestions for reducing this burden,to:Chief,Information Policy Branch,PM-223.U.S. BkPli lap,clOh..gaper/Plastic.hags.„ -;__, t` EnvironmentaLProtection.Agerm4'48d.M Street,SW,Washington,DG.20460:and to the Office of'Inf6mration zn 'ur. �:• 1 : ;.;,end Ftrgdlatory.Atlaury,41fC9sf,tA2na9frtinn4Af $ud9et,.WasMrrgtgL:DG2Q0.9• ,r !I'••rni1Q~ t T II :,ajgk : '1A tlo.1f ,J:3. ./� {�! P.tt'7 T;° 1070l 14A.` 1 WAV.+i711 � � r State f New Jglsey d G,� 4. f4,-M",��,,epartment h,,,of Enviftm enta1 Protection n I IIIIII IIIII IIIII IIIII IIIII IIIII III�I IIII IIII Hazardous Wast Regulat;br Program 5281848 Manifest Section. is P.O. Box 414, Tre4iYoji,7-.NJ..58625-0414 Please tVpe,or print in block letters.( m designed for use on elite(12-pitch)typewriter.) Form Approved. OMB No.2050-0039. UNIFORM HAZARDOUS 1.Generator's US EPA ID No.. Manifest 2. Page 1 Information in the shaded areas . r Document No.: WASTE MANIFEST a A t of a is not required by Federal law. 3. Generator's Name and Mailing Address A.State Manifest Document Number TJ9N,QFl1� ��. � . 44 :f i ��;, � NJA 5281848 w'+ 44A•J' STIAR.'5 T R lfta:'i S 11,14 01Z 0 1 B.State Generator's ID-(Gen.Site Address) 4. Generator's Phone , t,: -��,. 5. Transporter 1 Company Na'e 6. US EPA ID Number C.State+Trans ID-NJDEP >.i."` iq5 kii.iY°!•! )..s y s1 t' s Decal No. N 7. Transporter 2 Company Name 8. US EPA ID Number D.Transporter's Phone n E.State Trans.ID-NJDEP 9. Designated Facility Name and Site Address 10. US EPA ID Number Decal No.- N o� c7c"L U a1% e� F.Transportees Phone( ) d aSVi: I G.State Facility's ID 1Z 1); afL N i r " ,rj r fl f H.Facility's Phone( `4,.p) aka.,•,c � it. US DOT Description(IncludingProper Shipping Name,Hazard Class or Division, 12.Containers 13. 14. v. P ID Number and Packing Group) Total Unit Waste No. m HM- No. Type Quantity WtIvol a. :l a. N b• i�t°>; "v L `O.J&y Ab4J. s.,i,X-,1_, TOt;S.Yt i.i C, f C >. R W A C. _ .. o::.: T O' m' R Z , a, L T. itionai Descriptions for Materials Listed Above K.Handling Codes for Wastes Listed.Above al ! . a. P - C. a. C. lit+!L b. d. Tb. d. m 15. Special Handling Instructions and Additional Information d E d j� ;�j� 41,j j .` as p - yh= 1 p �{AM t+l'4�/ .T4it� �/t. 1J;1�w.I kd' vW 'Ti:� Yp!?A. �P� M�/}A.A1 •✓at+MRfX 64yf 6�. 16.GENERATOR'S CERTIFICATION: I herebydeclare that the contents of this consignment are full and accurately described above b proper shipping name and are 9 Y Y _Y P P PP 9 N classified,packed,marked,and labeled,and are in all respects in proper condition for transport by,highway according to applicable international and national government .� regulations. ti ca If 1 am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator,I have made a good faith effort to minimize'my waste generation and select the best waste management method that is available to me and that I can afford. Printedrrypad Name Signature Month Day Year E C T 17.Transporter 1 Acknowledgement of Receipt of Materials - o p Printedrryped Name Signature Month Day Year T ,N .,.. c S "a P. Z a`) .. p 18.Transporter 2 Acknowledgement of Receipt of Materials r aEi T Printed/Typed Name Signature �Na+Pay Year E _ ca R 19.Discrepancy Indication Space N F IV c 00 I 1 L I' 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. Y Printed/Type Name Signature Month Day Year EPA Form 8700-22 SIGNATURE AND INFORMATION MUST BE LEGIBLE ON ALL COPIES 7—GENERATOR MAIL TO-GENERATOR STATE Y, 0 'i TO1rKLr-CUA'NTITY-En1e, IQ totaC,q*titjIof wa*O diliscrl4d -6n each line. ATION qVitt'It 0i f . 7f r---- ... %. DO NOT USE FRACTIONS The Hazardous Waste npahffdjtJs`d0signed to track waste from the point lioni to fiita4goosd J-.f'!1 ":'11 1 11 1 gehera Item 14: UNIT(Wt.NoI.)-ErAehIia 3ppropriatid abbreviaton from Table It(bolow)for the unit of (cradle to grave).In order tcaccompifish this goal,it is essential that all items on the mam fiel;t be cgb= measure used in determining the total quantity of waste described on each line. plated correctly.Incomplete,incorrect or illegible manifests are violations of 4he law,�,A could you subject to civil or criminal liabilities as specified in the New Jersey HizsrdiidirWAie R6b6lafio)is. -S , 11! TAUT Ejl INSTRUCTI&S-4MP9FITAI -UNITS—, READ ALL INS-MIJGT16NS iIEFORE'r66MPLETU4G'1 U(,IFt AlrL oc G-Gallons(liquids only) Oederaf`�"`Iulal s require' '&Atpr� jranspqrteL�, td Tg _is Pf-P.tindr State lin iTritiaiinleni, 4to 'ippl -9;1-fo -V_nec7F�a; rvq! sheaf foF�0FAter--i-nd intrastate Facilities(TSDFs)to It Im fi�o y 'T�Tdr�'S(2000 Mg use e shipments. Contintfall",sheets S&tbr,purchajV I h Y-Cubic yards n-licial y and photocopied to provide copies as described below. L-Liters(liquids only) K-Kilograms The New Jersey rruapifiiist contains, 8 copies.."ALL COPIES I MUST BE LEGIBLE. This form M-Metric Tons(1000 kg) is'designed for use on a 12 pitch (elite) typewriter, a firm ball point pen may also be used N-Cubic Meters only if you press down HARD.The 8 co6les must be filed with the appropriate party as they are completed. . COPY DISTRIBUTION Is'as followg' Item,15: ---SP-ECIAL HANDLING.INSTRUr,110NS,ANO.ADDIt.tcit��INFORMATION L Use this space to Indicate special transportation.,treatment;storage,`disposal,or Bill of ORIGINAL: _,_DESTINAT1ONi.STATE180 to the state reg6litory agency Lading information, if any. If an alternate facility is designated, note it lifere. For where the facility is located.. COPY.2: —GENERATOR.ISTATE�Tbe_'TSDF:�.mails this copy. back-lo-the slate-regulatory INTERNATIONAL SHIPMENTS,generators must enter the point of departure(city agency where the waste was genereteql. ci, a i a)-1 K th irs 0 c-677h 18 t li'566 rha y'p 41p 6 u s d d F9 rte,in 9 rg a tic Y r0ls L COPY 3: GENERATOR copy_T a-TSDF_mails this-coo back to the generator of the telephone numbers,and any other Inf6imatioh the generator is requirbd to include waste. 4 ., , I I A . !,. , � i about the shipment in accordanca with 49 CFR Part 172,Subpart G as applija6le for COPY 4:' TSDF COPY=TSDP keOpIs this copy for his records. RCRA b..d...t.and USDOT-hazardous materials. I I * Item T6., GENERATOR'S CERTIFICATION he t6herator,niust read,sign(*:hantfi and data COPY_5: TRANSPORTER CQPY-TIV.1r1j1�.p.9�ej[J(eeps ti'lis-cppy for his records. r t ilit ie cerliff; NOTE: if a continuing,,franspollpr,is; I used-,the generator is responsible for ration.This must be done the day the transporter picks up the waste shi Tern(date 4"ipt dy supplying him--with—a legibke, "photocopy,t which must contain required transporter).If a mode other than highway is used,the word'highway"shoulld be lindd pptd and signatures. appropriate mode(rail,water,air)inserted in the space.It another mode in addition I.dig highway SATE is used,enter the appropriate additional Moderail')in this space. COPY'6: 'DESTINATION- STATE-The' jiine[a6r- mails thiJ copy to I the state I regulatory Item t STATE MANIFEST DOCUMENT NUMBER-Number preprinted by New Jersey Jxqept on"to agency where the designated fpcili� $61`))sfoaa�ted. I ' - -� - -11 1__;__i -i --continuatbn-si"ets:Ervterttms number omeech-cordinumhonsheet-atfthed-toamandist 6) GENERATOR STATEThe geriarator marls COPY 7: ls,,#i�:'copy to 'The state regula 9�ency where the waste was generated. ' loryiou ltem-B, t.,STATE GEN 46-ThA_&ate Gonaritiot 4D%fix street a4drets of lfi4,vk&egonetatloii site.If ItCe, I mailing adidreitt7rarrdlft Site address km,V*same,enter'same. I I CT COPY 8: GENERATOR COPY41R;generdtor keeps this copy for,his records. —ite,m,C:--._, STATE -Enter r state number.This mdAinclude both �e trani, kjE TRAN J1 IQ� ftl�iii" 'ALL11COMS MUST BE LEOBLF ._Vy_��a_ permit porter's permit number and the decal number of the hazardous waslIa transport unit on,hazardodi ACQUISITION+ MANIFEST FORM waste vehicle wtdch contains the v seta.For red sh' nt s enter a al numeric D numbed. l assigned to the railcar in lieu of thin decal n r. 1. If the destination (consignment)ignmeAt) state supplies a manifest & requires its use, then the Item D: TRANSPORTER PHONE-Enter a telephone number with area code where an authorized agent of generator is obligated toiobtain 'o manifest from that state.: the transporter can be reached. 2. If'th "dostination"'star does not'sUppi the,MarilleSt,"Wt-the generator state'does,-then lfeiWE� STAT81MAW2 IU-4f'jp�I1ca&t97efiier the New Jersey State permit number of thie waste carryin the generator is obligate to obtain the manifest form from the generator state. portion of the second vehicle.. 3. 1 neither the generator stag or the consignmeht state supplies toe manifest, then the Item F: TRANSPORTER PHONE-if aWcable,enter a telephone number with area cqde where,a.h author generator may obtain the manifest from any source. It i !zed agent of the second transporter may be reached. GENERATOR SECTION Item G: STATE FACILITY'S ID-No entry 13 required by Now Jesey. Item H; FACILIT-Y-PHONE-Eater a telephones number iNdth-area code of.the TSDF designated.to receive Item 17 G1tREAAtCGENERATOR'S EPA:iD`K?d.tMAjFE8f bb4buM-E KT'R�'CnLter the— the waste listed on the manifest. generator's EPA identIfication number.The 'manifest document number is a unique 5-digit numbdr the generator assigns to each manifest,for his rec6rdkeeping purposes, Item 1: WASTE NO.-Enter the 4-digit hazardous waste number as it appears in N.J.A.C.7:26G-54 et..seq• Use of,serfally increasing numbers�e.g,00001 (For example'K047'Is the waste number designated for pink/red water front I NT opprqtions.)The m page'7000,2,el lni�recommended. . 'L proper waste number that accurately descrbes the shipment,shall bi daterml iod accordiing to the Its' 2:_ PAGE 1 01-1—Entarlhalotal number bf 3,use", ipletelthis manifest; hierarchy-at fi-J.A.C.7:2(JG-ft.- - , I . — - Item 3: GENERATORS NAME&MAILING ADDRESS-Entei the name as notified to Z� i.e.the first page pluslithe number of confindation sheets,If any. I Item J: ADDITIONAL DESCRIPTIONS FOR MATERIALS AB�V Jiter desIption 40f antalysis for' any waste whlch does not have a complete USDOT shipping description orhi an , EPA)&mailing address of the generator.Tile address should be the location designation,Enter a general description of the waste stroam.Cw,groundwatersoantgLed that wi manage the returned manifest forms. with creosote and copper sulfate).Additionally,for any n.o.s.entry in lt�m 11 which dods not oonfo6i Ito 4:4: � !tqMBER' GENE ATOR'S PHONE. -Enter a telephone number with area code where an authorized agent QJ the generator cap be reached in an emergency. to the requirements at 49,GFR-112103(K)enter the two componentgeend their percentages, 4 Item 5: TRANSPORTER-1*COMPANY NAME-Enter the company name(as which most prodomantly'Ontribuld to the hazards of the'-mixture or solution.Enter the physical I state(S=Sp!A,L=Liquid,G=Gas,St.=Sludge)EPA hazard codes(I=Ignitable,C�,Corrosive; notified to EPA)of the first transporter who will transport the waste. lormati n a required Item 6: US EPA ID NUMBER-Enter the EPA identification number of the first R-Reactive,E=TCLP,H-Acute Hazardous,T=Toxic),Enter additional information transporter identified in Rem 5.1 1 by the waste code hierarchy at N.J.A.C.7:26-G-6.2. Itafn 7: TRANSPORTER 9 COMPANY NAME-If applicable,gnter'fK6'company rigrme- *TRANSPORTER SECTION (as notified to EPA)ol the second transporter who Y411 transport the waste, if more than two�2)transporters will be used,use a Continuation sheet and It is a violation by the transporter If he accepts hazardous waste from a generator who fails to propery qo plete t6' manifest,transports waste to an unauthorized facility,anftr fails to obtain the date and handwritten signature of the list the transporters in the order they will be transporting the-waste. -InOft hauler owneff6peratqr of,"T§Q facIA'Iy,PW-m Item'8: US EPA ID NUMBER-If a second transporter is used,enter the EPA 1 1, , � identification number of the second transporter identified in item 7. Item 17: ' TRANSPORTER I ACKNOWLEDGEMENT-Print or type the name of the person acpapting the Item 9: DESIGNATED FACILITY NAME&SITE ADDRESS-Enter the company name waste on behalf of the first transporter.That person must acknowledge acceptance of the -I and site address(as notified to the EPA)of the treatment,storage,or disposal waste described on the manifest by signing and entering the date of receipt. facility(TSDF)designated to receive the waste listed on this manifest.The Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-tt applicable,follow instructions for it,6i17 for the address must be the site address,which may differ from the mailing address.. second transporter. ' I f stern 1W-,- EPXI7NUMBER-E�,tbr;;h&EPA.*Idohdrlc%tton-iwbve�,bjptgWg NOTE.,.- 45:,I"TI-Ti�KNSPORTERS()PERATING IN-NEW JERSEY MAST HAVE A r v, (olr�49ie reuse facility)fiiW in Item S. _�bated`TSDF _OWANEV7 RAYAOIDOUS WASTE TRANSPORTER'S PERMIT. �tem' 11: 1.19DOT'DIESChIPTION-Enter the cbr,r6 bt USDOT shlOWliq aA;hazard class or division,the identification number and the packing group(49 CFR 172.202). DESIGNATED FACILITY(TSDF)SEcTidNI I The word waste must appear as part-of the USDOT6hi Nnamafftheqoaste pps .r Item 19:; n, DISCREPAN.GY INOCATION SPAGE-The authorized representative(41he designated facility must is ajecf4ral R9RA hazardous waste(49 CFR,l72.101).,F,&r awaste with a ri nole in th�.space any significant discrepancy between the waste descried on the manifest and L ri.(3.s.designation enter the 6ired by CPIR 172.203.Enter therite Ktua 6 facility,Any reij6.cladmaterials should be listed herb,pifiing ormatlon,�s rpq -fly received at'lp additional shippilng 69cription infitirmiti6n as i6q1ted by 4J'CFR'*2 Subpart with an explardtion of tte'disp6;fflori of th.-rejected wastes.Owitits'arid iriperators:ot,fac6fles it. C.IfiumthertAylastes are being shipped a-sepond mandw=.continualiqn:.�' located in ituffidAM!Stalei;(f:e.,Me Sfat0ig that received auth6irization It thq_�S,EPA to� administer!Wfi��d6us waste sh661d_c;nG4 their -16 nforroation qrf sheets stiould be used.For information on USDOT waste descriptions call your admin' . qigeltcy r ii USDOT nigional office. State Discrepancy Report requirements, Item 12j- C014TAINERS(NO.&TYPE)-Enter the number of containers for each waste Item 20: FACILITY OWNERIOPERATOR CERTIFICATION-Print or type the name of the persdnreceiving and the-apprdpriate abbiraiviiations from Tabler 1(bolft)-for theIX6-of Container— .the waste on behall.of the owner/operator of-the desigiWed-TSDF.That person musracknowledga. I used receivingther4,4lite Oemb-A on the writipst by signing and entering this-date of-rebelpt. J, --Item K- HANDLING-GGDE&-TSOFwSHQULD COMPLETE-Enter-tli&-ultirnato'hapdring method utilized at TABLE I the designated facility for each waste.Only the following prittess codes may be used;Storage=S0 (container):SO?(Tank);SO4(Surface Impoundment);S05(Other-specify);Treatment=T01 CONTAINER TYPES (Tank);T02(Surface Impoundment);T03(Incinerator);T04(Other specify);DisposalID79 T i DM--Metal drums,barrels,65—s —(InjiXVbn Well);,D80(LandfiT lot8l"Wilir, VcTn),-D8,>JQcsary qlsposal):'Dil� DW-*ood&a dr",barrials,kegs (Surface Uhl the intdi-stat6145inen�-yotl mdy1q`requi&d to-comply with1he marfifi5sBir g reqbirelnenks of bog DF-FiberbPA or plastic drums,barrels,kegs 6 TP:Tan the consignment and generator states regarding the completion of specific inforritatfori included T bar ks in)soared items A-K. Please check with both generator and consignment states for specific �tanks(Tank trucks) TC_T.g _A_ -requirements-New.Jerseykequit 1haLall.WQrmabait befilled in exceplJo0em V. k 17 A DT-Dump truck "o Q CY-Cylinders C,i CM-Metal boxes,cartons.cases(including roll offs) Public reporting burden for this collection of information is o0mated to average:37 minutes for generators,15 minutes for transporters,and 10 minutes for treatment,storage and disposal facilities.This includes fime for reviewlirg CW-Wooden boxes,cartons,cases instructions,gathering data,and completing and reviewing the form.Send comments regarding the burden CF-Fiber or plastic boxes,cartons,cases estimates including suggestions for reducing this burden,to:Chief,Information Policy Branch,PM-223;V.S. BA-Burlap,cloth,RaRer pl,�Stic_bags cl— Euirortmantal Protection Agency,40-1 M Street SW..Wa0irQWr4 J)Q 2W0,,,and_to the Office of jnfdrnjaOon r" %%rj J 4, in 1,1, 1 1,...qand RQ9qIat9ry Affairs,91fice of MapegemenRaqd B09ot YilaslbingtoR.))C 20503, J.,A Firs i t, -.0" 'I"Ji -3TA'1'P .:0T.4R3V:l0-0TJ1,0X State gf New Jersey / / Department of Erivirental Protection.� ( F Hazardous WastewReguFa�S��n Program - Manrfes�SectIor . F P.O. Box 414,Trenton"hIJ 08625-0414 = Please type or print in block letters.( designed for use-on elite(1 2-pitch)typewriter.) Form Approved. OMB No.2050-0039. UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Page 1 Information in the haded areas ?" Document No. �, WASTE MANIFEST of is not required by' Federal law. 3. Generator's Name and Mailing Address A.State Manifest Document Number D-4,Of. ��AL x�'W,4 fti a'At ��. D,.: , ; NJA 5281848 1 044 AA N y r { y, gy j r B.State Generator's ID-(Gen.Site Address) 4. Generator's Phone �i9i.. �: �.t.r. �`� "• r +? +�*• .. 5. Transporter 1 Company Name 6. US EPA ID Number C.S1ate}TraAs ID-NJ t EP +, " Decal No.- a 7. Transporter 2 Company Name 8. US EPA ID Number D.Transporter's Phone E.State Trans.ID-NJDEP 4 N 9. Designated Facility Name and Site Address 10. US EPA ID Number Decal No.- o> _ F.Transporter s Phone( ) G.State Facility's ID 51 av,... ect3. , ? d n , ;IAt1 ? H.Facility's Phone w 11. US DOT Description(Including Proper Shipping Name,Hazard Class or Division, 12.Containers 13. 14. ' 'o ID Number and Packing Totl Unit m HM Grou p) No. Type Quantity Wt/vol Waste No. WAO N G b• .N. Ya' + s ` r,c'�.4$.;.s!!ii.,t. a. yi;6i;. + i. ir- ;[ p }y, C J + E E ,� xt �, .#�siti:z,irr, iia a kt.4.rtk'1 .� c N N .5 R LL A c. O T O a R N d. z mJ. Additional Descriptions for Materials Listed Above K.Handling Codes for Wastes Listed Above -o a. C. a. C. o +N €3i > b. d. b. d. U m 15. Special Handling Instructions and Additional Information 2) xr 1�F(Et$ «. tA�r i 1 , IasiIt:f m E ;',a atl t11 16.GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are N classified,packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government D regulations. cc If I am a large quantity generator, I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present y and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation is and select the best waste management method that is available to me and that I can afford. Printed/Typed Name Signature Month Day Year E i.. N T 17.Transporter 1 Acknowledgement of Receipt of Materials o p Printed/Typed Name Signature Month Day Year N . S "4 - rn P a� 0 18.Transporter 2 Acknowledgement of Receipt of Materials T Printed/Typed Name Signature � n h y Year c E rC R o 19.Discrepancy Indication Space N c° F N U c A C 1 L �. 1 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. E yPrintedrryped Name Signature Month Day Year �*,• EPA Form 8700-22 SIGNATURE AND INFORMATION MUST BE LEGIBLE ON ALL COPIES 8—GENERATOR COPY I GENERAL INFORMATION Item 13: TOTAL QUANTITY-Enter the total quantity of waste described on each line. DO NOT USE FRACTIONS The Hazardous Waste manifest is designed to track waste from the point of generation to final disposal Item 14: UNIT(Wt.Nol.)-Enter the appropriate abbreviaton from Table II(below)for the unit of (cradle to grave).In order to accomplish this goal,it is essential that all items on the marrfest be'com_ plated correctly.Incomplete,incorrect or illegible manifests are violations of the law,arr'd could make measure used in determining the total quantity of waste described on each line. you subject to civil or criminal liabilities as specified in the New Jersey Hazardous'Waste Regulations. TABLE II INSTRUCTIONS-IMPORTANT: - _ UNITS OF MEASURE READ ALL INSTRUCTIONS BEFORE COMPLETING G-Gallons(liquids only) State & Federal regulations require Generators, Transporters, and Treatment,.Storage & Disposal_ _ P-Pounds Facilities(TSDFs)to use this form and if necessary the continuation sheet for both inter-and intrastate T-Tons(2000 lbs.) shipments. Continuation sheets may be purchased'commbrcially and photocopied to provide copies as Y-Cubic yards described below. - - "*' L-Liters(liquids only) K-Kilograms The New Jersey manifest contains 8 copies. ALL COPIES MUST BE LEGIBLE. This form M-Metric Tons(1000 kg) is designed for use on a 12 pitch (elite) typewriter; a firm ball point pen may also be used N-Cubic Meters only if you press down HARD.The 8 copies must be filed with the appropriate party as they are completed_. Item 15: SPECIAL HANDLING INSTRUCTIONS AND ADDITIONAL INFORMATION- COPY DISTRIBUTION is as follows: T Use this space to indicate special transportation,treatment, storage, disposal,or Bill of ORIGINAL: DESTINATION STATE-TSDF must mail original to the state regulatory agency Lading information, if any. If an alternate facility is designated, note it here. For where the facility is located. i r INTERNATIONAL SHIPMENTS,generators must enter the point of departure(city& COPY 2: GENERATOR STATE-The TSDF mails this copy back to the state regulatory 'agency where the waste was generated. state)in this space.This space may also be used for emergency response COPY 3: GENERATOR COPY-The TSDF mails this copy back to the generator of the telephone numbers,and any other information the generator is required to include waste. about the shipment in accordance with 49 CFR Part 172,Subpart G as applicable for COPY 4: TSDF COPY-TSDF keeps this copy for his records. RCRA hazardous waste and USDOT hazardous materials. COPY 5: TRANSPORTER COPY-The transporter keeps this copy for his records. Item 16: GENERATOR'S CERTIFICATION-The Generator must read,sign(by hand)and date the certrfl- NOTE: If a continuing transporter is used the generator is responsible for cation.This must be done the day the transporter picks up the waste shipment(date of receipt by supplying him-with a legible photocopy, which must contain required transporter).If a mode other than highway is used,the word"highway'should be lined out and the signatures. appropriate mode(rail,water,air)inserted in the space.If another mode in addition to the highway COPY 6: DESTINATION STATE-The generator mails this copy to the state regulatory mode is used,enter the appropriate additional mode(e.g."and rail")in this space. • agency where the designated facility(TSDF)is located. Item A: STATE MANIFEST DOCUMENT NUMBER -Number preprinted by New Jersey except on the continuation sheets.Enter this number on each continuation sheet attached to a manifest. COPY 7: GENERATOR STATE-The generator mails this copy to the state regulatory Item B: STATE GEN'ID-The State Generator ID is the street address of the waste generation site.It the agency where the waste was generated. mailing address and the site address are the same,enter"same". COPY 8: GENERATOR COPY-16 generator keeps this copy for his records. Item C: STATE TRAN#1 ID-Enter the New Jersey state permit number.This must include both the trans- ALL 8 COPIES MUST BE LEGIBLE porter's permit number and the decal number of the hazardous waste transport unit or hazardous MANIFEST FORM ACQUISITION waste vehicle which contains the waste.For rail shipment(s)enter the alpha numeric I.D.number assigned to the railcar in lieu of the decal number. 1. If the destination (consignment) state supplies a manifest & requires its use, then the Item D: TRANSPORTER PHONE-Enter a telephone number with area code where an authorized agent of generator is obligated to obtain the manifest from that state. the transporter can be reached. 2. If the destination state does not supply the manifest, but the generator state does, then Item E: STATE TRAN#2 ID-If applicable,enter the New Jersey State permit number of the waste carrying the generator is obligated to obtain the manifest form from the generator state. portion of the second vehicle. 3. If neither the generator state or the consignment state supplies the manifest, then the Item F: TRANSPORTER PHONE-If applicable,enter a telephone number with area code where an author= generator may obtain the manifest from any source. !zed agent of the second transporter may be reached. GENERATOR SECTION Item G: STATE FACILITY'S ID-No entry is required by New Jassy. Item 1: GENERATOR'S EPA ID NO.-MANIFEST DOCUMENT NO.-Enter the Item H: FACILITY PHONE-Enter a telephone number with area code of the TSDF designated to receive the waste listed on the manifest. r generator's EPA identification number.The manifest document number is a unique Item I: WASTE NO.-Enter the 4-digit hazardous waste number as it appears in N.J.A.C.7:26G-5.1 et.se . 5-digit number the generator assigns to each manifest,for his recordkeeping purposes. (For example"K047'is the waste number designated for pink/red water from TNT operations.)The Use of serially increasing numbers(e.g.00001,00002,etc.)is recommended. proper waste number that accurately describes the shipment,shall be determined according to the Item 2: • PAGE 1 Of Enter the total number of pages used to complete this manifest; - hierarchy at N.J.A.C.7:26G-6.2. i.e.the first page plus the number of continuation sheets,if any. Item J: ADDITIONAL DESCRIPTIONS FOR MATERIALS LISTED ABOVE-Enter description of analysis for Item 3: GENERATOR'S NAME&MAILING ADDRESS-Enter the name(as notified to any waste which does not have a complete USDOT shipping description or has an n.o.s. EPA)&mailing address of the generator.The address should be the location designation.Enter a general description of the waste stream.(i.e.groundwater contaminated that will manage the returned manifest forms. with creosote and copper sulfate).Additionally,for any n.o.s.entry in Item 11 which does not conform Item 4:. GENERATOR'S PHONE NUMBER-Enter a telephone number with area code to the requirements at 49 CFR 172.203(K)enter the two components,and their percentages, where an authorized agent of the generator can be reached in an emergency. which most predominantly contribute to the hazards of the mixture or solution.Enter the physical Item 5: TRANSPORTER 1 COMPANY NAME-Enter the company name(as state(S=Solid,L=Liquid,G=Gas,SL=Sludge)EPA hazard codes(I=Ignitable,C=Corrosive, notified to EPA)of the first transporter who will transport the waste. R=Reactive,E=TCLP,H=Acute Hazardous,T=Toxic).Enter additional information as required Item 6: US EPA ID NUMBER-Enter the EPA identification number of the first by the waste code hierarchy at N.J.A.C.7:26-G-6.2. transporter identified in item 5. Item 7: TRANSPORTER 2 COMPANY NAME-if applicable,enter the company name TRANSPORTER SECTION (as notified to EPA)of the second transporter who will transport the waste, It is a violation by the transporter if he accepts hazardous waste from a generator who fails to property complete the if more than two(2)transporters will be used,use a continuation sheet and manifest,transports waste to an unauthorized facility,and/or fails to obtain the date and handwritten signature of the list the transporters in the order they will be transporting the waste. next hauler owner/operator of the TSD facility on the manifest. Item 8: US EPA ID NUMBER-If a second transporter is used,enter the EPA identification number of the second transporter identified in item 7. Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT-Print or type the name of the person accepting the Item 9: DESIGNATED FACILITY NAME&SITE ADDRESS-Enter the company name waste on behalf of the first transporter.That person must acknowledge acceptance of the and site address(as notified to the EPA)of the treatment,storage,or disposal waste described on the manifest by signing and entering the date of receipt. facility(TSDF)designated to receive the waste listed on this manifest.The Item 18: TRANSPORTER 2 ACKNOWLEDGEMENT-If applicable,follow instructions for item 17 for the address must be the site address,which may differ from the mailing address. second transporter. Item 10: EPA ID NUMBER-Enter the EPA identification number of the designated TSDF NOTE: ALL HAZARDOUS WASTE.TRANSPORTERS OPERATING IN NEW JERSEY MUST HAVE A (or waste reuse facility)listed in item 9. VALID NEW JERSEY HAZARDOUS WASTE TRANSPORTER'S PERMIT. Item 11: USDOT DESCRIPTION-Enter the correct USDOT shipping name,hazard class or division,the identification number and the packing group(49 CFR 172.202). DESIGNATED FACILITY(TSDF)SECTION The word waste must appear as part of the USDOT shipping name if the waste Item 19: DISCREPANCY INDICATION SPACE-The authorized representative of the designated facility must is a federal RCRA hazardous waste(49 CFR 172.101).For a waste with a note in this space anysignificant discrepancy between the waste described on the manifest and n.o.s.designation enter the information as required by 49 CFR 172.203.Enter the waste actually received at the facility.Any rejected materials should be listed here,along additional shipping description information as required by 49 CFR 172 Subpart with an explanation of the disposition of the rejected wastes.Owners and operators of facilities C.If more than 4 wastes are being shipped,a second manifest or continuation located in authorized States(i.e.,those States that received authorization from the U.S.EPA sheets should be used.For information on USDOT waste descriptions call your to administer the hazardous waste program)should contact their State agency for information on USDOT regional office. State Discrepancy Report requirements. Item 12: CONTAINERS(NO.&TYPE)-Enter the number of containers for each waste Item 20: FACILITY OWNER/OPERATOR CERTIFICATION-Print or type the name of the person receiving and the appropriate abbreviations from Table 1(below)for the type of container the waste on behalf of the owner/operator of the designated TSDF.That person must acknowledge used: receiving the waste described on the manifest by signing and entering the date of receipt. Item K: HANDLING CODES-TSDF SHOULD COMPLETE-Enter the ultimate handling method utilized at TABLE 1 the designated facility for each waste.Only the following process codes may be used:Storage=S01 1 (container);S02(Tank);SO4(Surface Impoundment);S05(Other-specify);Treatment=T01 CONTAINER TYPES (Tank);T02;3urface Impoundment);T03(Incinerator);T04(Other-specify);Disposal=D79 DM-Metal drums,barrels,kegs (Injection Well);D80(Landfill);D81(Land Application);D82(Ocean Disposal);D83 DW-Wooden drums,barrels,kegs (Surface Impoundment):D84(Other-specify). DF-Fiberboard or plastic drums,barrels,kegs 'NOTE For interstate shipments you may be required to comply with the manifesting requirements of both the consignment and generator states regarding the completion of specific information included TP-Tanks portable TT-TCargo tanks ank trucks) in lettered items A-K. Please check with both generator and consignment states for specific TC-Tank cars requirements.New Jersey requires that all information be tilled in except for Item'G'. ♦ DT-Dump truck CY-Cylinders Public reporting burden for this collection of information is estimated to average:37 minutes for generators,15 minutes CM-Metal boxes,cartons,cases(including roll-offs) for transporters, and 10 minutes for treatment, storage and disposal facilities. This includes time for reviewing CW-Wooden boxes,cartons,cases instructions,gathering data,and completing and reviewing the form.Send comments regarding the burden CF-Fiber or plastic boxes,cartons,cases estimates including suggestions for reducing this burden,to:Chief,Information Policy Branch,PM-223.U.S. BA-Burlap,cloth,paper/plastic bags Environmental Protection Agency,401 M Street,SW,Washington,-DC 20460:and to the Office of Information and Regulatory Affairs,Office of Management and Budget,Washington,DC 20503, COMMONWEALTH OF MASSACHUSETTS .Q DEPARTMENT OF ENVIRONMENTAL PROTECTION 1/h DIVISION OF_HAZARDOUS MATERIALS II One Winter Street Boston, MtLssachusetts 02108 ' PI ase print or type.(Form designed for use on elite(12-pitch)typewriter) UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest Document No. 2.'Page 1 Information in the shaded areas WASTE MANIFEST I n 1.0 , . ` f�. of is not required by Federal law. 3.Generator's Name and Mailing Address A State Manifest Document N -' or T0 `" aA€ a LE BEAuTH Dlv s oaa MA .Q 8 61 5 9 I"i p State Gerf.lD' 4.Generator's Phone( r,pig);{aj Gfr,A ,+ a ,� O N 5.Transporter 1 Company Name p 6.US EPA ID Number C State Trans ID M 0000 lrxXAN itRNTURF, TRC__ 4,A''a' y "" „r'� Ems•' r 7.Transporter 2 Company,Name 8.US EPA ID Number D STrans orters f'Ewne RJ N E StateTrans fD U1 9.Designated Facility Name and Site Address 10.US EPA ID Number K" O (ME37AI, tKICAL CORPORATION F TransportersPhone( ) ��� 3aLsrA�i�. ��.�,�:�� G.,.StateFacility'sI© `"2 NOT REQUIRED` ` tP'cC1b.�i:i�GrdiK, , . DIM, a;� ;� ca � > A, I-� F,aellltys none( ) n !` 11.US DOT Description(Including Proper Shipping Name„Hazard Class and ID Number) 12.containers is. „ I O No. Type Total Quantity w of WASTE ND: a. a V E b. y R f 9 D CE NTATE ht AOt O A _ 'rw �"d s d Z �4 ,"t,'.. '�i t..-..r�� P'"!k ' a 9 r CU T c. O R m -C 4. k L k,:*-,) t>3 d. Z O Z . (ts CO I J Additronal,Descrrptrrns#or Maferrais Usted Above include physical state and hazard K Handiang Cvices for Wastes Llate[f Agave :q,_y 15 a& 15.Special Handling Instructions'and Additional Information U CVO 117 1-3,05 3326 - n k1l a) 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, O packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If I am a large quantity generator,I certify that I have a program in place to reduce the volume and•tozicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management method that is available-to me and that I can afford. ' Date N Printedl.TypedName Signature lr _' Month Day Yea to ,-. U TR', 17.Transporter 1 Acknowledgement of Receipt of Materials • r Date N Printed/Typeed Name Signature r` Month Day Year p ('.» t e'er I/ ~ R 18.Transporter 2 Acknowledgement of Receipt of Materials Date E Printed/Typed Name Signature Month Day Year R F 19.Discrepancy Indication Space A i C L X.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in iteml9 j I Date YPrintedlTyped Name signature Month Day Year Form Approved OMB No.2050:0039. EPA Form 8700-22(Rev.9-99)Previous editions are obsolete. , COPY>6: GENERATOR MAILS TO DESTINATION STATE INSTRUCTIONS FOR COMPLETING THE UNIFORM HAZARDOUS WASTE MANIFEST Item 12:CONTAINERS(NO.&TYPE) Enter thexnumber of containers for each waste and the appropriate abbreviations from Table I IMPORTANT:READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM -j~ - , (be16w)rf6r tirB',typ2.'ofco'ntainerLi ed. '�3: ti}.J P v S 1 J 8 - - - - - ,TABLE I—CONTAINER TYPE - State and Federal regulations require Generators,transporters,an—d Treatment,Storage,and Disposal Facilities(fSDFs)io ue th sis form Y-- 1 r + and,if nec®ssary ithe Continuation Sheet for interstate and intrastate shiprriems of hazardous wastes. DM=Metal drums,barrels,kegs DW 'Wooden.drums,barrels,kegs, DF=Fiberboard or plastic.drums!barrels, pp f 3 TP=Tanks,portable TT-Cargo tanks(tank trucks) f kegs The MA mlinifest'contains 8 copies.ALL;COPIES MUST BE LEGIBLE!-(Iflegifile manifests submitted-to the State will be returned to the 1,-- i enerator for ro er cpm letion.This form is designed for use one 12 Itch eThe ewriter.A firm ball point en may also be used if you DT=Dump trticTi I CY=Cylinders TC=Tank cars ", G , 9 P p P ) 9 P T )?YP, p P Y Y CW=Wooden boxes,cartons,cases CF=Yiber or plastic boxes,cartons,cases CM=Metal boxes,cartons.cases(incl. press down+iARD.Each f the 8 copies must be filed with-tne appropriate party as it is completed.Copy distribution is as follows: , 1 i roll offs) 4- m....' ","' COPY 1; DESTINATION STATE—Mailc?if tiyTSDF.the original stayswith the shipment from generation to completion by the TSDF. J + BA-Burlap,doth_paper/plastic bags When the manifest is completed;thelTSDF must mail thislcopy to the state where the facilitytg�s located: r I g ( Item 13:TOTAL QUANTITY—Enter the total quantity of waste describ d on each line. COPY 2: GENERATOR STATE—Mailedfby TSDF:When the TSDF has completed!his section of the manifest,he mails to to the r I !. Stale where the waste was enerated. I f ' ii -Item 14:UNITS(Wt./Vol.).—Enter the appropriate,abbreviation from Table 11(below)for the unit of measure used in determining the total g i 6 S quantity of waste described on each line.Do not use fractions. i g""� ; v COPY 3: GENERATOR COMPLETED COPY—Mailed;by TSDF,When the TSDF has completed his section of the manifest,he mails this TABLE II,—UNITS OF MEABURE i (tom! n copy back to the Generator of the waste who must retain it on-site for his,re(iotrds. COPY 4: ISDF COPY:When the TSDF has comp pile d his section of the manifest,he keeps this copy(or his records. ( G=Gallons(liquids only) L-Liters(liquids only)• P`Pounds + � T=Tons(2000 lbs.) Y=Cubic-Yards I K-Kilogramsl 0 rs COPY 5: -tRANSPORTEq 1:When,the transporteLhecompleted'+ his sectiQn-of the manifest and transferred-the waste to the TSDF,he M=_Metric Tons(1000 k_g) _ y _ _N=Cubic Meters. i s _ keeps this copy for his records.}.. , F - 1 - d - ' r - c i_. ! *Item I:WASTE NO.—Enter the 4 digit EPA haz�rdouswaste hur fber as"it appears in 40 CFR Part 2fi1`Subpzr`�ts C and b.if a non-RCRA t ram' _ DTE:If a continuing transporter is used,thelgenerator s responsible'forsiipplying him with a legible photo-copy of the manifest, State-regulated wastestream is being manifested, enier,the State hvaste•code here. If both the Desfnation rid Gene ator States have which riiust contain signatures where required. - t- assigned codes.use the Destination State code.If there is.no EPA/ t2te code,enter'nonl. COPY 6: DESTINATIOJ�STATE—Mailed by Generator:WF�en the Generator has completed his section of the manifest and transferred his t,*Item J:ADDITIONAL DESCRIPTQNS FOR MATEMAt,'S LISTED ABF2VE-Enter descript n of analysis.tot any aste which does not have waste to the transporter,[e mails this copy to the State where the designater}ltacility(TSDF)is located ( a U.S. DOT shipping name or has an N.O.S. designatiori. Enter constHuei t percentages, chemioal'hames! physical istates,(S=Solid, { { - � --L=Uquid,G-Gas,SL=Sludge)tand EPA Hazard'Codes(Ignitable(1),Corrosive(C),Reactive(R),&Toxicity(E),Acute Hal4dous(H), COPY 7: GENERATOR;STATE—Mailed;by Generator:When the generator has completed his section of the manifest and transferred his Tox c(T), Enter the specific gravity if other than 1.0.Any additional desired waste description may also'be entered here.to u n t waste t6 the transporter,he mails this copy tothe State where the waste was generated. i - ------ __eT� _ —_,_� ,__ y ._,_. d _ _i ( `� 7 t c 1 = i Item 15: SPECIAL HANDLING INSTRUCTIONS AND ADDITIONAL INFORMATION—Use this space to indicate spea8l transpo'rtatlon,_.1 COPY 8: GENERATOR;When the1Generator has completed his section'of the maVest and transferred his�naste to th ..transporter,he treatment, storage or disposal or-Bill of Lading lfiformation. If an alter(Sate lac lity (TSDF) is designated, note it here,For tnternatigta(ilt� » keeps this copy for his re ords.f i , , ' { i shipments Generators must enter the point of de arture Ci and State from the,US thro h which the waste ust-travel efon enterin a(V -w— P P dL ( tY )' E�9 n_ ST S 1 } GENERATOR SECTION I k foreign country'.This spec"e maj a sf o be used fore ilergency response telephone numbe(S,and other information the(5eneraSor vplahesj 2of= I ( ) - r I 4 _ include about the.shipment,including placarding.1 1-_ 1..- r +( - > item 1:GENERATIOR'S'US EPA ID VO.—'MANIFEST DOCUMENT+NO.—Enter the US EPA generator's 12 digit identification number.Then f S t _ ®Hier a unique 5 i d number you assi n to this manife Use of seriail mcjeas!pg gumbers a 00001,00002,etc., is recgplmended. k_ *Item K:HANDLING CODES—TSDF Completes thi5section—See"Designated Facility Section"(below). iJ 9 �9 Y 9 y _:c 7 ( g' ( ) i i. ,im n. -1 ` 'Item 16:GENERATOR'S CERTIFICATION—The Generator must read,sin b ) -( Item 2: PAGE 1 lot^ —Ent Jr the total numberiof pages used to con piete,?his manifest, i,e.,the first form plus the Wmber�of _ _ _ - 9 ( yhand and date the certification with 1 to ofaransfer-to GpntinuatiQn Sheets,if any.Any EPA approved continuation sheet:may be,tiaed,but�istribution and'completidn must meat Massachusetts ' traa0bA67f.Ilia m6bl`6—b 'ii-r than highway is used,the word highway`should be lined Out and the appropriate mode(rod,water or.ak) . manifest requirements. yy r i m `, { inserted in the space below.If another mode in addition to the highway mode is-used,enter the appropriate mode(eg."and radj iretlae [; 1 I 1 d f space below.On signing the waste minimization(cert fixation statement, those generators who have not been exempted by statute or f .Item A:STATE MANIFEST DOCUMENT NUMBER—Number preprinted by MA.exoapt on the Continuation Sheets.Enter this number in regulation from the duty to make a waste minimization certification underlbctiori�002(b)of RCRA are also certifying the t3�kiey have compjjed ttem L on each Continuation Sheet mttachdd to or part of a manifest: I with the wastelminimization requirements. -, D 1 mr I t WI D1 i 1 , Item,3:GENERATOR'S'NAME AND.MAWING ADDRESS—Enterthe name(as.notifiedYo EPA)and mailing address of The Generator.This 1 TRANSPORT]�SECTTON G' address should be the Iodation that will rganage the returned manifest forms. .. . '` �,. •4 - I { I r Item 17:TRANSPORTER 1 ACKNOWLEDGEMENT. Print or typear!e name of the-person accepting the waste on behalf of the fusty Item 4:GENERA PHONE NIB Enter a telephone ember with area Code where an authorized agent of the.Clenerator can be Transporter.That person must acknowledge acceptance of the waste described on the maytitest by signing and entering the date of receipt. I reached inlan em r enc: -- } g •%`•Y( t ! ,-- i i - �'( Item 18:TRANSPORTER 2 ACKNOWLEDGEMENT*Inapplicable,follow the instructions for Item 17 for Transporter 2. :'Item B:STATE GEN ID I-The State Generator ID is the street address of the.Generagor's pick-up location.If the mailing address and the street addrF ss are the same,enter"fame"in 4 block. >! ' - - ! ; DESIGNATED FACILITY'(TSDF SECTION Item 5:TRANSPORTER 1 COMPANY NAME-L Enter the Impany namef(as notified to EPA)of the.first transporter who Lit transport the i Item K:HANDLING CODES:TSDF SHOULD COMPLETE—Enter the ultimate handling Method utilized at the designated facility fSr each x waste. ! 1 } c waste listed in Item 11.Only the following process codes may be used: i tjem 6:US EPA ID Number—Enterthe US EPfAf 12 digit identification number�f thefirst transporterld'entified in ttem 5 x + 4 ```TABLE 111—PROCESS CODES 1 Q Item C:STATE TRAN'ID—Enter the Stateof registration and the license plate number of the waste-carrying portion x>f the vehicle being STORAGE , so,4G.Mire�) Soz rraek/, ,5ai xwaaiePilo) ( Sa(Soda..My und—hi) loin SOAw (` used to make the' ick-u tj ,�„ ` -i -j TREATMEr� Warid4)CFRp.265,Append.I,Teda2 � f � � �- j (J I Pi t p i t r DISPOSAL ! 079 pnied on wail) D80(Lammry) 681(Lang Appl,cal,on) 082(Ocean Disposal) oevg,udace Irrtp.) *Item,,O:TIRANSPORTER'S PHONE—EP ter a telephtne number withxarea code whiare an authorized agent of the transporter can be oe4(0mxsp&ity) reached 1 i - I I 1 r m t, 1. 4 _ (. - Item 19:DISCREPANCY INDICATION SPACE—The authorized representative of the designated facility's owner or operator must note in this Item 7:TRANSPORTER 2iCOMPANY NAME- If applicable enter the ce�mpatly name jas notified tq•, PA)of the second transporter who will . space any significant discrepancy between the waste described on thg,manifest)and the waste actually received at the fac�lity.Any rejected transport the waste,If more than two transporters will de used,use a ContinuatioQSheet and list transporters in the order they will be materials should be listed here,`along with an indida£on of the disposition of the rejected materials.Any applicable Discrepancy or Exception transporting the vleaste. 4 2 44:I 1 i reporting requirements must also be complied witfi.Federal and stater ulations may vary. • ¢ � P 9 q I �. e9 Y e.! Item 8:US EPA 19 NUMBER—If applicable,•enter the US EPA 12 digit identficationnUmber of the"Ansporter id item 7. Item 20:FACILITY OWNER OR OPERATOR CERTIFICATION—.Print ortype the name of the person accepting'the waste on behalf of the I + f + owner or operator of the designated TSDF.That person must acknowledge acceptance of the waste described!on the manifest by signing *Item E:STATE TRAN ID if applicable,enter the second ttanspotter'sState of registration and license plate number for the waste carrying b hand and the date of receipt,The si nature of the author ed TSDF agent indicates acceptance of(except items specified in portion of Te vehicle being used to rake the pick-up. ) l e - ! ( Y ) 9 P• 9 K 9 P (p P _ P q e o 1 Item 19)and agreement with statements on this manifest. + *Item Fr TIANSPiORTI�'S PHONE—If pplicable enter toe second transporter's telephone number with area code where an authorized agent of th transporter can be ri aj fed. L l _ I { NOTE:FOR INTERSTATE SHIPMENT YOU MAY BE REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF•BOTHMikfE 11 ! 11 DESTINATIONAND GENEBATCk STATES REGARDING THE COMPLETION OF.SPECIFIC INFORMATION INCLUDED 11�L.iTYERE EMS` Item 9:DE31GNA7ED FACILITY NAME AND$ITE ADDRESS—Elmer the-company name(as notifiTF to EPA)of the TSDF designated to A-K. j o *• 1 li- i! ll+� r i receive the-waste tisted-on this ma est<;The-a dress must the site address,which.r}�y differ frofAailing address. ' 1 -J 1 - 3;. i t =f 3( - I , >lr - 1 BURDEN STATEMENT The public reporting burdenfCr this coliectior)of information is estimated to average 31�a inutes for wnr ratprs,t6' Item 1$U!EPA ID NUM�ER—E er the�15 EPA 12�igifident fc2tion number^of the designated TS listedir)Item 9. minutes for transporters,and 16 minutes for treatment,storage and.disposal facilities.The recordkeeping burden per iespprisc for' *Item Gr STATEku CIL(7NS ID—No eMfy is required;by fyla sact)usetts - C t S t collection of information is estimated to average 6 minutes for generators,6 minutes for tia0 porters,and 6 minutes for.tieaihlem,storage (d J t 1 .ra_ and disposal facilities.The burden associated with reading the regulations is estimated of f`hour and 15 minutes annually.Burden means 1 c L n n ' the total time,effort,or financial resources ex *Item Ht ACILITI(PHONE—Enter a telephone number v gth arBecode f6r3tie T6Dl designated toe�eive the waste listed on the manifest. Derided_by persons to generate,rriaintain,rreta n,ordisclos@ or provide information to or for a r t Federal agency. 4 I w ;I R f t n !,Jf Item 11:US DOT DESCRIPTION'--All pf the following inlust besntered`The7correct UL DOT(Department of Transportation)name for the i i ,;.- t ' ( r t t waste as identified in 49 CFR Parts 17t=M(usually;foun in golumn 2 df SeCti6n 172.101),the'assigned DOT Hazard,Class(usually in An agency may not conduct or gponsor,and a person,is not required to;respondlto,a collection of information unless it waste curPently column 3)and the 4 digit UN/NA ID number•(columm 3A)l(e.d.l Waste Sulphuric Apo,spent,corrosive material,UN?,8,92RQ).US DOT,t valid OMB cor)trol number.The-OMB numbers for EPA's regulations aa✓e listed in 40 CFR•Part 9 and 48 CFR Chapter f5.Se d"corinfrt�nls requires the word"waste before or in theshipping name for all hazardoas•waste. ——j ----� —t^---- t — aegarding-these burden statei iAts-or enyether es ect of this collection;including suggestions for reducing the burden,-- cfudipg thrQUgh -• _ - U D c r, .i the'113e`10f-automated col(ectlon techniques to the Director,OPPE Regulatory Information Division,U-S.Environmental ProtectioiFAgency. M St, S.W.;Washm on,-D:C 20460;and to the Office of Information and Regulatory Affairs,-Office of Management and Budget, (2137),401 gl eg +Y Affairs,-O tJ). 20111, :i Li! ) ^t t,^9 Jt + 050on Desk 0#(isBr for EPA;725i�7th Sheet N:W/ whin ton'D.C:20503:Y Include the wOMB control number in any correspondence.* �- -1 fl t r h' 9_ . = COMMONWEALTH OF MASSACHUSETTS ' r DEPARTMENT•OF ENVIRONMENTAL PROTECTIONV/s/0 (o jDIVISION OF`f1AZAR66US MATERIALS t -One Winter.Street Boston;Mtssachtts'etts 02108 Pl se print or type.(Form designed for use on elite(12-pitch)typewriter) UNIFORM HAZARDOUS 1 Generator's US EPA ID NoNi-. M2nifest'Document No. 2. Page 1 Information a the shaded areas WASTE MANIFEST of ; is not required by Federal law. 3.Generator's Name and Mailing Address v u ' A State Manifest Document Number TOWS 01F 3-AIMS AUX KBALTH DIVATS1 1 :MA .'Q 8;61259'' '�LATK STREET B State Gen tD 4.Generator's Phone t. _.� yi A °v » D N 5,Transporter 1 Company Name w`" 6.US EPA ID Number C State Trans AD d ` ��' t +"tt .f•t M ^r se N <° f '- o. Ir""�` t 7..Transporter 2 Company Name. 8."US'EPA ID Number D Tra�spprters Phone{ � j a .�t Rl .. t � E State Trans,ID 1 yl" ^ �`: " Ln ,� 9.Designated Facility Name and Site Address 10.US EPA ID Number "i 0 (ax-ERA L CwtCA t CORPORATION F Transporters Pttone(:: i 133 4914"D STREz-T G,State Facility's1D SNOT REWIRED W t"AINGMX.s MA 01702 1r s s a - a ,I IH.Facihty's;Phone(r 11.US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) t2:CorltainOs 13 �';- � No. Type Total Quantitym w WASTE NO U a. . v O z Q G � «' m aw E b. E c R O A r tts T c. cn z O STATE RtGULI1 -0 0T.'..7 LIQUID 0 R { Z _ .I (73 d. y U >+ O CD d Addltiona(Descriptions for Materials Listed Above(include physical sii`tate and hazard code) K Handling Codes for 1Na%es Listed Above m c. a bM, a w L 15.9Special Handling Instructions and Additional Information o CV Jr 01 ORDERi 6 111 . >« 24 HR. Eli# 508* 74' 3000 CLW VIZ4 ME N 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, 0 packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If I am a large quantity generator,I certify that 1 have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically C practicable and that I.have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human; C health and the environment;OR,if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management U method that is available to me and that I can afford. O Date N PrintedlTyped Name Signature F r Month Day Year. • :♦ U TR 17.Transporter 1 Acknowledgement of Receipt of Materials Date != N PrintedlTyped Name Signature y' Month Day t Year P "t+..,: r r ': p 18.Transporter 2 Acknowledgement of Receipt of Materials J ' ( Date E Printed/Typed Name Signature Month Day Year R F 19.Discrepancy Indication Space A C 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in item19 Date T PrintedlTyped Name Signature Month Day Year Y Form Approved OMB No.2050-0039. EPA Form 8700-22(Rev.9-99)Previous editions are obsolete. COPY>7: GENERATOR MAILS TO GENERATOR STATE INSTRUCTIONS FOR COMPLETING THE UNIFORM HAZARDOUS WASTE MANIFEST �r� „ Itgm\12' ONTANERS(iVO,:&TYpF,)- Enter th number of containers for earn we hste and the appropriate abbreviations from Table 1 IMPORTANT:READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM 1 T' '2+" 'JAB.-)(below)-for the type'`rif Eontainer1,sed:M 1 z 1 it-IJ It ?_V CI t4 l-, \tin —TABLE VI -CONTAINER TYPE —- - _ State andtFederal regulations reg6,ire G nerators,transporters,and Treatment,Storade,and Disposal Facilities(TSDFs)lto use this form• s and,if necgssary`the'Continuation Sheet for interstate and intrastate sApn!�Os?;)f hazardous wastes. I DM=Metal drums,barrels,kegs DW J Wooden drums,barrels,kegs j OF=Fiberboard or plastic drurns;lar(els, < TP=Tanks,portable t 'fT=largo tanks(ankitrucko, t kegs t n The MA Manifest contains 8 copies7ALL COPIES MUST BE LEGIBLE! @69ible manifests submitt: ',o the State will be-returned to the DT=Dump truck CY=Cylinders TC=Tank cars =' generator!or proper completion.)Titis forr)t is designed for use onta 12 pitch-lote)'tXpewriter.A firm all poinI* an may also be used if you I CW=Wooden boxes,cartons,Cases CF=.Fiber or prastic boxes,cartpns,icases CM=Metal boxes,cartons,cases(mcl. press down HARD.Each.of the 8 copies roust be flied 04b the appropriate padj�strt L completed.C py distribution is asfollows: t r ') roll-offs) k G '+ y = t �f"''�'4 COPY 1: DESTINATION STATE--Mailed by TSDF,iha 4l inal staye with the shipthen f from generatipn to completion by.ttie TSDF. `! _ BA=Burlap,clbtR`par er a54ic bags iftn the manifest is completed,the TSDF must m !this copy to the state here the facility is located. , I d t 1 t , Item 13r TOTAL QUANTITY-Enter the total'quantity of waste described on each{fine. COPY 2: GENERAT R STATE-,Mailed by TSDF;When the TSDF has bbmplete'd:his section of the manifest,he maitsrthis copy to the F-'Item 14:UNIT Wt.Nol. 1 pp p a j below) t g State.wher the waste was generated. { '' , ` " f.-r _ ( )-Enter the a ro riate abbrevi tiomfi'Om'Table I below for}he unit of ntaast]fe u ed7 n.,dett?rminin the total 4 _ 1 � _''{!j 1 } t i quantity of waste described on each line.Do not use`fractiobs.' l ( f COPY 3: GENERATOR COMPLETED COPY_Mailed by TSDF.When the TSDF hascompleted hisectin of the manifest,he mails this, �`s - - �' TABLE 11-1-UNITS OF MEASURE 1(,„ 1 copy back to the Generator of the wast,ee��whd muit retain it on site fot his teseirds. �' - D l COPY 4: TSDF DOPY:When the TSDF his completedthis Jectionpf the manifest,He-keeps this copyforhis records ` f u=Gallons(liquids only)' ! L=Lifers(liquids only), Pounds ?1 ' Mi f { l 1 T=Tons(2000 tbs.) ( Y=Cubic Yards t K=Kilogram ri 0 t: COPY 5: TRANSPORTER 1 Whe the.tans o er ttas completed his section"oi,the manifest and transferred the waste to TSDF M=Metric Tans f 000 k N=Cubic Mee t 9 e'(`/ p tti@_ _tee _ , __ �,.s __.� _ f � � j keeps this copy for his r ords. jj ` "1 f .,._-• +- 4 i ;1 _ *Item I:WASTE NO.-Enter the 4 digit EPA hazardouslveste ntxh er asd ears in-40 CFR Part"26 u15p rts C and•D"If a non-RCRA NOTE:If a continuing transport 'thl generators respoasTbta fon supplying him with a legible photo-cooy of the manifest, State-regulated v astestream is4 being manifested, enten the:State waste_cpaelhere. I both the Destination and Gene}for States have yahich�ust contain signatures w e r( ired. t i _ !- ,_ y assigned codes use the Destination Stale code.If there is�a£P. Late co41e;enter"norla"COPY 6: DESTIATION'STATE iMailed by eneratdr:When the Generator hasrComPleted his sell of the manifestVd.transferred his *Item J:ADDITfONAt DESCRIPTIONS FOR MATFrRIALS LISTEt7 A®OVE o Enter description of analysts r anoviaste.whi<h does not have Waste to the itdnsporter,he mails this copy to the State where the designated facility(TSDF)is located. ' a U.S. DOT shipping name 4 has an N.O.S.designation. Enter constituent iperceiitages,chemicar'IiAmB s, phys l�states.(S=SoI`�1, 11 j J L=Liquid,GZs;SL=Sludge)and EPA Haze odes(Ignita bl''((1),CorrosiLe JC),reactive(R),EP Toxicity(E),A•1 �az_ardousq), COPY 7: GENERATOR STATE- ailed.by Generator:When the generators oofipleted his section of the,manifest and transferred his Toxic M. Enter the specific graLity if other than 1¢Anyadd tiohatdesired desired - c��n may also be entered Here i 1 =i � li waste tb the transporter, a ma is this copy to the State where the waste was generated. Y - '( � -- L ! I E t .t1 + ,, -. f Item 15: SPECIAL HANDLING INSTRUCTIONS AND.IADDITIONAL INFORMATION -Use this space to indicate speclat tr4hsportation,.ry -COPY 8: OENERATO(4:(When the,Generator:has completed his!section of this manifest and transterred his waste to the transporter,he treatment, storage or disposal or of Ledingp'fo motion. If an altgrhate faailify-(TSDF) is designated, note it hete.[t-ors-}htem'ati6`-.1) f keeps his copy for his ref{cords.) t f+ _t shipments,Generators must enter the point of depart,a(City and Statekfrom th ttS through which the waste roust traVel•befgre a ytgri1V aQU T! rk [ ' yENERATOR SECTION',i` �lorelgn c`ounity.This space may also be u'se3 fogy enp@rgency response elephorse numbers,and other information the Generator wishEaitor ± F. include about#he_shipment including placarding. .Item 1:GENERATOR S{US EPA ID PO.--I MANIFEST 90CVMENT NO.-;Et ee the US,EPA generator's 12 digit identification number.Then ! ( T ,'enter a unique 5 di tt number you assign to this manifest.Ube of serial) increasin ;umbers a 00001,00002„etc., )s recommended Item K:HANDLING CODES-TSDF Completes I.,Iection-See"Designated acility Section"(below). t .J{- u r r 9 Y jj 9 Y 9 ( 9 ) - _ltem 2: PAGE 1 r of t -Enter the itotal number,of pages{used to;aompleie;This manifest, 4e., the fist form plus t17�clan pbe )item 16:GENERATOR'S CERTIFICATION-The Generator must read,usign(bi hand)and date the certification(with drtEe bf transfer to`� 5.Continuatipn Sheets,a y.Any E A app6ved continQatiob sheet may b0 USed,but distribution and completion must meet Massachusetts 'fanspoiter} if a mode other tan i igf way is used,the word"highway,-shouldtlbe linediout and the appropriate mode{rail,i ater_o4ir)'j Wit#anifest r0quirements.,( ! 1 i - :{ i t i inserted in the space below.If i3nother mode in addition to the highway mode is used enter the appropriate mode leg. and da�'j in•k e C'J t i ! i space below. In signing the waste minimization certification statement, those generators who have not been exempted by stab&Dr *Item A:STATE MANIFEST DOCUJA.ENT NUMBER-,Number preprinted by MA except on the Co tinuation Sheets.Enter this number in+ regulation froth the duty to make a waste minimization certification under sectidn$002(b).df RCRA are also certifying thaEfhey have cmmpliec- item L on each CbMinriation Sheet ttached tcl or part of a manifest E -�••-I { ! with the waste•minimization requirements. d, S W �'1 rf a t c, t ( .item 3:GENERATOR'S,,NAME AND Mi4 NG DDRAS--dEnter the name�as ndSy 9d:to EPA)and mailing address of iha Generator.This � { TRANSPORTE5$ECT9QN._ r A Laddress should be therlocation that will rtanade the re� rneo maniftest forms - 'oa I y; t - p 7 l s t ri t v I t { Item 17:TRANSPORTER 1 ACKNOWLEDGEMENTA Print or typel'ilie nar;e�of the>; son accepting the waste on ehaif+of t4effirst. :item 4:GENERATOR'S PHONE NUMBEY-Enter a%telephone gumber with else node where an authorized agent of the Cpenerator can be Transporter.drat person must acknowledge acceptane of the waste describe fin the manifest by signing and entering thdatyof race pt. �r .reached in an emergency. r { - ) ' ', t y 1 t i c L y - }f i { r ' v. t "I Item 18:TRANSPORTER 2 ACKNOWLEDGEMENT If applicable,folio the inst uctions for Item 17 for Transporter 2. GItem B:S ATE GEN JD r The State Generator ID is the street address of the Generator's pick-up location.l the-maili g ddress and the i t d z - r s t - - q i DESIGNATED FACILI DF ECTION Tsftreet addg"ess are the same,enter am in this block., _ y 1 t r t )� r , Q -Tljam 5 TRiANSPORTE€1 COMPA[Y NA.,E Enter the company name{as riot ed to EPA)of the firs[transporter who will transport the, Item K:HANDLING CODES:TSDF SHOULD COMPf ETE-Enter the Itima[e handling method utilized at the;designaiod facility or each:. aste. ! T ( l t waste listed Item 11,Only the foflowing process'cod(?s may be used: _ t I Q TABLE III-PROCESS ODES } ( I (4) 1� < �em 6:U EPA Iq NuOPT r-Enter the A EPA 12 digit idei tification num(er-of the first,transporterjdentified in Item 5, 0### f ! � t 3 :` � 1 ... i *Item C: ATE TRAN-fD-Enter,the State of registration}and t e license. gb number of.the waste-carrying portion rf the vehicle being I srow,oE• + so,rea,�an�+rs) sot rra<tq� aa,Rvai,a r,�) { spa isunace mpw,rctmarn) sroa+a yl i TREATMENT Reler t 40 CFR pad 2;T.Apper�."t.Table 2' 'Used tom ke the peck Up. { I _ l Q 1 { t ! ( t �\ -.1 j{ {�1 1 , DISEOSPtI. t D19(ln;st0on tve"}. DB'J lLaOtl�,"' Dot,ld,q AppBeatgn) 082(Ocean D,spgsaq, D 31Suelaelro 1 J '(.Item:): RAN OR R'S PHONE.-Enter a telep tie number with area corie,where an au&rized agent of the tr nsporter can be{ i o 4 ph.sp ) } I I I .7bach_ed 1 t 1 :t o z S =t . 9 ¢` 1 f� { ' t r t �_ A ! €f l Item 19;DISCREPANCY INDICATION SPACE-*e:authorized'represe{tative ofithe designated facility's owner pr dperaloi must note in this G2em 7:TRpNSPORTER'2 COMPANY NAfYtE. If appliC it enter the company nahia.(as notified to EPA)of that second trr,'ansporter who will! space any si ificant discrepancy between the waste ifescribed on the Manifest and the waste actually received at the facility.Any rejected transport the waste.If more than t{Mo transgof.ers will be used,use a Dfi[ 1u`ation Sheet and Ilst.the transporters in the:order they will be' materials shot Id be listed"here,along with an indica3lon of the disposhilop of the r�jected materials.Any applicable Discrepancy or Exception [ransportirig the waste i t ^; + ' _ _ ( :�, Y i reporting reqY rements must alsto��be complied with.jzederal and state`regutations,may vary. Item t3:US EPA ID NUfa1�ER--If a�iplicable;enter the U$'E'?A 12 digit idedbficATion'number of the tra�lsporter in item 7. ! j, Item 20[FACILITY OWNER OR uPERATOR CERTIFICATION-Printi,oqq type th{name of the person acre)#trig the waste on behalf of the t T' owner or operator of the designated TSDF.That parsoh must acknowledge acceptance 4f the waste described on the manifest by signing *Item E:STATE TRAN 1D!-If applocable,'ert the second transpgrter's Sta[ of registr Lion and li$erjse plate number lot ilia waste carrying portion of the vehicle being used to makedl )tick-up. E I i 4 i ( (by hand)anctentering the.dateof receipt.The signature of the authorzed TSDF agent 17�it(icates acceptance(except'£o 1,items specified in • _ i R ` Item 19)and agreement with statements omthis rr�pifesI *ItenfF xT NSPORTERiS PHONE-If applicable,enter rya second transporter';alephone numbeQr with area code wh t e an authorized l 1 t iii { ( y c I t NOTE:FOR INTERSTATE SHIPMENT YOU MAY18E FEQUIRED TO COMPLY V1frrH THE MANIFESTING REO IREc.N��"Cr�T �F B FH T E agentbf a tranSporterCan be re�Fhed. I i - {{ ( -'t ' P., N d ! # 1 { •< 1 y( ' DESTINATION AND GENERATOR STATES REGA DING THE COMPLETION OF SPECIFIC INFORMATION Its DEJ'D" � ER P 1;TEtviS, , Item 9:,DESIGNATED FACILITY NAME AND SITE ADQRESS-Enter the-company name(as notified to EPA)of the TSDF designated to f A-K. I 1 y yf receive the west listed on this r Tanifest.The addressor st be the cite address,;which stay differ fr6rp mailing address. 1 ' ye( a`r 1 s tt r r BURDEN STATEMENT The public reportingq burden for this collectiottbf information Is btlj{nated to averaged minutes for genet ors,15 Item 1U.�US EPA ID NUMBER-=Eater thg US EPA 12d gat ipeniifiCatiomn dmtier.of2hQ designated FSbF listed in Item 9. f minutes for transporters,and tS minutes for treatment,storage and':disposal facilities,The recordkeepmg Orden per ir£sportse foc,this 1 iitti r M f r collection of information is estimated to average 6 minutes for generators,6 rgiqutes for transporters,and 6crnoutes fir treatment,storage *ItemC-,SPATE FACILITY'S ID-,No entry is regwredlry Issai$u"setts c ( i gg _ ( and disposal facilities.The burden associated with-reading the regulations is estimatedet 1 hour and 15 minutes`antt}tally.Burden means *Item..`FACILITY PHONE--Enter a tele hone numbertyith area Fode for the TS13Fdesignated to receive the waste listed on the manifest. !! the total time,effort,or financial'resources expended by persons to gerierate,`maintain,retain,or disclose orr vide in brrnation to-grfgr a Q. I Federal agendy. 3 i i Item 19;US DOT DESCRIPTION T AIP k the following must be entered;Thg correct US DOT(Department of Transportation)name for the 1 LV t washes'entif ed inp8 CFR Parts 17f-177(usually found in-column 2 of'section 17,2.101),the`assigned DOT Hazard lass(usually in' An agency may not conduct or¢ponsor,and a person is not requiredq respond to,a cbllep}ion of informatitj nibs;itdpl�ys a curientty, colummo 3) and tt e 4 djgit UN/NAND nymbei(column 3At. (e.g:Waste Sulphuric Aoid,spent,Cprroswe maferial,UN, 2RQ). US DQ�• valid OMB cod trot number.The OMB numbers for P1A's regulations ar listed in 40 CfR Part 9 and 48 CFR Chdtiter 15.SeKd comments A requires'tl word"waste before orin the shipping nameforf all hazardous waste '^� - --- — - - regarding these-burden statements "ny other-aspeeteif-this•collectioh;irtcluding suggestions-for•reducing the-burderrinctedini'th uui�) f 1 y •1 ,.. . [ tha.PfsEof automated col£ectibn'#achniques to the Director,OPPE Regulatory Information Division,U.S.Environmental Protection Agency. - -i24 37)-4G1-IV}St;S-W.-Washington;-D.0,20460;-end te4he Office o[Infermatiorrand Regulatory Affairs;Office-of Management and Budget, �� 11. l-:7i�`: 0,1 E JJ3•.LaiLiC:A 0'. 2t'a-ip' r.�.,!'1,-i�t�.�� Ya;9i, Att"dl)lbe$k'Offi.cerlotFFA72517tti.Street'K'W...VashriborijfiG 20 031In tldetheOMBcontrolnumberinanycorrespondence: ,• COMMONWEALTH OF MASSACHUSETTS DEPARTMENT�OF,ENVIROOENTAL PROTECTION DIVISION OF AAZAR.POUS MATERIALS One Winter Street Boston, Mcftssachus6tts 02108 P15gse print or type.(Form designed for use on elite(12-pitch)typewriter) UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest Document No. 2.Page I Information in the shaded areas WASTE MANIFEST of is not required by Federal law. 3.Generator's Name and Mailing Address A State Manrfest Document Number T004 OF DAPATIABLE RE&VTR DIVISALONN m-S"g zoo NATR STREn Z > mg 4.Generator's Phone jj e) k.3fiP C) r. CY 5.Transporter 1 Company 6.US EPA ID Number a 0 02 Er 00 00 — C.IXAM VR$T-;TRV. �Nr I I ill �11 ed 'N1 -d �l ,I 1 -1 7.Transporter 2 Company Name 8.Us EPA IDD-Numb6r lb�t6a'�n'zs` e," ru C\1 Ln 9.Designated Facility Name and Site Address 10.US EPA ID Number 0 Y'7 0 QVINUA* MMOuTCAL fX1PORATIONTransportersPWn 00 133 L91-AND S- TIREST *911 K 91 0 W FWNUAX lu�, 0 17 0 2, Im Ih 14 1 t%I I fitI 1 -11 11 J -d J�,o fify 0 ! 11.US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) 19'.Conlaine'rs 13. unk No. TVpe Total 0 t/Vol WASTE,140;— uantity W a. 77777-11 V 00 WASTY, MERCURY U) UN24 F,RG 17 2 M 0 vu Z M. d. d h QL G E b. Cr N -STATE. R.F.M.-AT ED OILY W'"lix; 0 E 'V R 4 0 A1:- M 0 T c- Cn Z 0 �;TATE REGUIXIMD OlLf LlQUID R M 0 d. ZZ >1 41 c, co AM 'I'litk C I Wastes Above Handling --Z 01 i E 4 Z -�A E QL 3all"k-2,11W i - 0M ll, ; V — '...... L d 4 15.Special Handling Instructions and Additional information 11R. ZO YK-972 5000 UZA Cv F. 10? JOAO 311764 -In 417 0) 16.GENERATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, 0) packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically practicable and that I have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human E health and the environment;OR,if I am a small quantity generator,I have made a gooVaith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. 0 F Date (D Printed/Typed Name Signature Month Day Year T 17.Transporter 1 Acknowledgement of Receipt of Materials Date R A Printed/Typed Name Signature f Month Day Year N S P k- 0 R 18.Transporter 2 Acknowledgement of Receipt of Materials ' PrintedlTyped Name Signature bate E Year R F 19.Discrepancy Indication Space A C 1 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in item19 L I Date Printed/Typed Name Signature Month Day Year Form Approved OMB No.2050-0039. EPA Form 8700-22(Rev.9-99)Previous editions are obsolete. COPY>8: GENERATOR RETAINS INSTRUCTIONS FOR COMPLETING THE UNIFORM HAZARDOUS WASTE MANIFEST Item 12:CONTAINERS(NO. &TYPE) Enter the number of containers for each waste and the appropriate abbreviations from Table I IMPORTANT:READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM (below)for the type of container used." 1•• {`�.`- State and Federal regulations require Generators,transporters,and Treatment,Storage,and Disposal Facilities(TSDFs)to use this form TABLE I—CONTAINER TYPE + and,if necessary,the Continuation Sheet for interstate and intrastate shipments of hazardous wastes. DM=Metal drums,barrels,kegs DW=Wooden drums,barrels,kegs OF=Fiberboard or plastic drums,barrels, TP The MA manifest contains 8 copies.ALL COPIES MUST BE LEGIBLE! (Illegible manifests submitted to the State will be returned to the =Tanks,portable TT=Cargo tanks(tank trucks) kegs D generator for proper completion.)This form is designed for use on a 12 pitch(elite)typewriter.A firm ball point pen may also be used if you T=Dump n b CY=Cylinders C =Tank cars press down HARD.Each of the 8 copies must be filed with the appropriate party as it is completed.Copy distribution is as follows: CW=Wooden boxes,cartons,cases CF=Fiber or plastic boxes,cartons,cases CM=Metal boxes,cartons,cases(incl. roll-offs) - COPY 1: DESTINATION STATE Mailed by TSDF:the original stays with the shipment from generation to completion by the TSDF. BA=Burlap,clotfr,`paper/plastic bags When the manifest is completed,the TSDF must mail this copy to the state where the facility is located. Item 13:TOTAL QUANTITY—Enter the total quantity of waste described on each line. COPY 2: GENERATOR STATE—Mailed by TSDF:When the TSDF has completed his section of the manifest,he mails this copy to the Item 14:UNIT(Wt.Vol.)—Enter the appropriate abbreviation from Table 11(below)for the unit of measure used in determining the total State where the waste was generated. quantity of waste described on each line.Do not use fractions. COPY 3: GENERATOR COMPLETED COPY—Mailed by TSDF:When the TSDF has completed his section of the manifest,he mails this - - ^�^ TABLE II—UNITS OF MEASURE ti.f copy back to the Generator of the waste,who must retain it on-site:for his records. a G=Gallons(liquids only) L=Liters(liquids only) P=Pounds .� COPY 4: TSDF COPY:When the TSDF has completed his section of the manifest,he keeps this copy for his records. T=Tons(2000 lbs.) Y=Cubic Yards K=Kilograms ti COPY 5: TRANSPORTER 1:When the transporter has completed his section of the manifest and transferred the waste to the TSDF,he+ _ M=Metric Tons(1000 kg) N=Cubic Meters ' keeps this copy for his records. *Item I:WASTE NO.—Enter the 4 digit EPA hazardous waste number as it appears in 40 CFR Part 261,Subparts C and D.If a non-RCRA NOTE:If a continuing transporter is used,the generator is responsible for supplying him with a legible photo-copy of the manifest, State-regulated wastestream is being manifested, enter the State waste code here. If both the Destination and Generator States have which must contain signatures where required. assigned codes use the Destination State code.If there is no EPA/State code,enter-'none". r i COPY 6: DESTINATION'STATE—Mailed by Generator:When the Generator has completed his section of the manifest and transferred his. _ *Item J:ADDITIONAL DESCRIPTIONS FOR MATERIALS LISTED ABOVE—Enter description of analysis for any waste which does not have waste to the transporter,he mails this copy to the State where the designated facility(TSDF)is located. a U.S. DOT shipping name or has an N.O.S. designation. Enter constituent percentages, chemical names, physical states (S=Solid, L=Liquid,G=Gas,SL=Sludge)and EPA Hazard Codes(Ignitable(1),Corrosive(C),Reactive(R),EP Toxicity(E),Acute Hazardous(H), COPY 7: GENERATOR STATE—Mailed by Generator:When the generator has completed his section of the manifest and transferred his Toxic(T). Enter the specific gravity if other than 1.0.Any additional desired waste description may also be entered here. - waste to the transporter,he mails this copy to the State where the waste was generated. Item 15: SPECIAL HANDLING INSTRUCTIONS AND ADDITIONAL INFORMATION— Use this space to indicate special transportation, COPY 8: GENERATOR:When the Generator has completed his section of the manifest and transferred his waste to the transporter, he- treatment, storage or disposal or Bill of Lading'information. If an alternate facility (TSDF) is designated, note it here. For international keeps this copy for his records. ; shipments,Generators must enter the point of departure(City and State)from the US through which the waste must travel before entering a GENERATOR SECTION foreign country.This-space may also be used for emergency response telephone numbers,and other information the Generator wishes to include about the shipment,including placarding. 1 Item 1:GENERATOR'S US EPA ID NO.—MANIFEST DOCUMENT NO.—Enter the US EPA generator's 12 digit identification number.Then enter a unique 5 digit number you assign to this manifest.Use of serially increasing numbers(eg.00001,00002,etc.,)is recommended. *Item K:HANDLING CODES—TSDF Completes this section—See"Designated Facility Section"(below). Item 2: PAGE 1 of_ —Enter the total number of pages used to complete this manifest, i.e.,the first form plus the number of Item 16:GENERATOR'S CERTIFICATION—The Generator must read,sign(by hand)and date the certification(with t+�,+,te of transfer to Continuation Sheets,if any.Any EPA approved continuation sheet may be used,but distribution and completion must meet Massachusetts transporter).If a mode other than highway is used,the word"highway"should be lined out and the appropriate mode(rail,water or air) manifest requirements.' inserted in the space below.If another mode in addition to the highway mode is used,enter the appropriate mode leg."and rail")in the space below. In signing the waste minimization certification statement, those generators who have not been exempted by statute or *Item A:STATE MANIFEST DOCUMENT;NUMBER—Number preprinted by MA except on the Continuation Sheets.Enter this number in regulation from the duty to make a waste minimization certification under section 3002(b)of RCRA are also certifying that they have complied Item L on each Continuation Sheet attached to or part of a manifest. with the waste minimization requirements. s Item 3:GENERATOR'S NAME AND MAILING ADDRESS—Enter the name(as notified to EPA)and mailing address of the Generator.This TRANSPORTER SECTION address should be the location that will manage the returned manifest forms.- i Item 17: TRANSPORTER 1 ACKNOWLEDGEMENT—Print or type the name of the person accepting the waste on behalf of the first - ,Item 4:GENERATOR'S PHONE NUMBER—Enter a telephone number with area code where an authorized agent of the Generator can be Transporter.That person must acknowledge acceptance of the waste described on the manifest by signing and entering the date of receipt. Breached in an emergency. Item 18:TRANSPORTER 2 ACKNOWLEDGEMENT—If applicable,follow the instructions for Item 17 for Transporter 2. *Item B:STATE GEN ID—The State Generator ID is the street address of the Generator's pick-up location.If the mailing address and the DESIGNATED FACILITY(TSDF)SECTION street address are the same,enter"same"in this block. , .street 5:TRANSPORTER 1 COMPANY NAME—Enter the company name(as notified to EPA)of the first transporter who will transport the Item K:HANDLING CODES:TSDF SHOULD COMPLETE—Enter the ultimate handling method utilized at the designated facility for each waste. waste listed in Item 11.Only the.following process codes may be used: _ Item 6:US EPA ID Number—Enter the US EPA 12 digit identification number of the first transporter identified in Item 5. 1 TABLE III—PROCESS CODES - *Item C:STATE THAN iD—Enter the State of registration and the license plate number of the waste-carrying portion of the vehicle being STORAGE so,(co mamma) S02(rank) fio3(waatePne) Boa(Sanace Impoenamem) Soy(Omer-Specify) used to make the pick-up. - TREATMENT Refer to 40 CFR part 265,Appendix 1,Table 2. f t r DISPOSAL 079(Iniectien wel0 080(Lanmllt) D81(land Application) 082(0oean Disposal) D83(Surface Imp.) *Item D: TRANSPORTERS PHONE—Enter a telephone number with area code where an authorized agent of the transporter can be De4(Other SRenity) I reached , { ` ' Item 19:DISCREPANCY INDICATION SPACE—The authorized representative of the designated facility's owner or operator must note in this Item 7:TRANSPORTER 2 COMPANY NAME'—If applicable enter the company name(as notified to EPA)of the second transporter who will. space any significant discrepancy between the waste described on the manifest'and the waste actually received at the facility.Any rejected transport the waste.If more than two transporters will be used,use a Continuation Sheet and list the transporters in the order they will be materials should be listed here,along with an indication of the disposition of the rejected materials.Any applicable Discrepancy or Exception transporting the waste. reporting requirements must also be complied with.Federal and state regulations may vary. Item 8:US EPA ID NUMBER—If applicable,_enter the US EPA 12 digit identification number of the transporter in item 7. Item 20:FACILITY OWNER OR OPERATOR CERTIFICATION—Print or type the name of the person accepting the waste on behalf of the *Item E:STATE THAN being —If applicable,enter the second transporter owner or operator of the designated TSDF.That person must acknowledge acceptance of the waste described on the manifest by signing s State of registration and license plate number for the waste carrying (by hand)and entering the date of receipt.The signature of the authorized TSDF agent indicates acceptance of(except for;items specified in portion of the vehicle being used to make the pick-up. - Item 19)and agreement with statements on this manifest. ' *Item F:TRANSPORTER'S PHONE—If applicable,enter the second transporter's telephone number with area code where an authorized NOTE:FOR INTERSTATE SHIPMENT YOU MAY REQUIRED TO COMPLY WITH THE MANIFESTING REQUIREMENTS OF BOTH THE agent of the transporter can be reached. DESTINATION AND GENERATOR STATES REGARDING THE COMPLETION OF SPECIFIC INFORMATION INCLUDED IN LETTERED.ITEMS Item 9:DESIGNATED FACILITY NAME AND SITE ADDRESS—Enter the company name(as notified to EPA)of the TSDF designated to A-K. receive the waste listed on this manifest.The address must be the site address,which may differ from mailing address. BURDEN STATEMENT The public reporting burden for this collection of information is estimated to average 31 minutes for generators,16 Item 10:US EPA ID NUMBER—Enter the US EPA 12 digit identification number of the designated TSDF listed in Item 9. minutes for transporters,and 16 minutes for treatment,storage and disposal facilities.The recordkeeping burden per,response for this *Item G:STATE FACILITY'S ID—No entry is required by Massachusetts. collection of information is estimated to average 6 minutes for generators,6 minutes for transporters,and 6 minutes for treatment,storage and disposal facilities.The burden associated with reading the regulations is estimated at 1 hour and 15 minutes annually.Burden means *Item H:FACILITY PHONE—Enter a telephone number with area code for the TSDF designated to receive the waste listed on the manifest. the total time,effort,or financial resources expended by persons to generate,maintain,retain,or disclose or provide information to or for a Federal agency. Item 11:US DOT DESCRIPTION-All of the following must be entered:The correct US DOT(Department of Transportation)name for the waste as identified in 49 CFR Parts 171-177(usually found in column 2 of section 172.101),the assigned DOT Hazard Class(usually in An agency may not conduct or sponsor,and a person is not required to respond to,a collection of information unless it displays a currently column 3)and the 4 digit UN/NA ID number(column 3A). (e.g.:Waste Sulphuric Acid,spent,corrosive material,UN1832RQ). US DOT valid OMB control number.The OMB numbers for EPA's regulations are listed in 40 CFR Part 9 and 48 CFR Chapter 15.Send comments s requires the word"waste"before or in the shipping name for all hazardous waste. - -regarding these burden statements or any other aspect of this collection,including suggestions for reducing the burden,including through W the'use of automated collection techniques to the Director,OPPE Regulatory Information Division,U.S.Environmental Protection Agency- (2137),401 M St.,S.W.,Washington,D.C.,20460;and to the Office of Information and Regulatory Affairs,Office of Management and Budget,. Attention:Desk Officer for EPA,72517th Street,N.W.Washington;D.C.20503.Include the OMB control number in any correspondence. �. f __ NON-HAZARDOUS 1.Generator's US EPA ID No. Manifest Document No. 2.Page 1 WASTE MANI'FEST IM P 5 6 8 8 2 . y. l .. of .3.Generator's Name and Mailing Address A. TOL�'N OF BARN5TABI,E M HEALTH DIVISION 200 MAIN 'STREET B.State Gen.ID N3XANAiIS, MA 02601 11$9 '"PHINNEY°S LANE, 4,Generator's Phone( ) (� G 1,5 BARNS AALE. 14A 02630 5,Transporter 1 Company Name 6.US EPA ID Number C.•State.Trans:ID. CLEAN VENTURE INC. IN .3 U 10, 10 10 10 2" 7 'l 1913, `�C) `�,,�. f' 7.Transporter 2 Company Name 8.US EPA ID Number D:Transporter's Phone ,( ) 5 E.State Trans.ID 9.Designated Facility Name and Site Address 10.US EPA ID Number GENERAL- UHMICAL, CORPORATION F.Transpdrter's Phone ( ) 133 LELAND STREET G.State Facility's ID NOT REQUIRED FRAMINGHAM, MA 01702 ;is A ID 0' 1119 3 7 1 -0 7 1.9 H.Facility's Phone ( ,O ) R72 5000 11.US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) 12.containers i. No. TypeTotelQuantity Un,t www WASTE NO. - a' BATTERIES, WET, FILLED WITH ACID MA99 8, UN2794, P13I11, ERG154 G Y ' X. E b. N ANON RCRA NON DOT REGULATED MATERIAL AiA99 E (LATEX & OIL BASED PAINTS). R T c. O NON RCRA NONODOT REGULATED MATERIAL . MA99 R (EMPTY CONTAINERS T,AST- CONTAINING: F' -* 3 ? ),k,I /•:�' /,0 4 d. J.Additional Descriptions foe Materials Listed Above(include physical state and hazard code.) K.Handling Codes for Wastes Listed Above TREAD ACED BATTERIES EMPTY PAILS a. c. ,►?c a: C. PAINTS IN ORIGYN'AL CONTAINER. b. X 5~'.�✓ d. b' d 15.Special.Handling Instructions and Additional Information CVI:-07 OBLDER# 61712 24 HR. N R# 508-872 -SOLO . CLEO' VENTURE CVI 07. 30B# 33?69 1Q,-07 16.GENERATOR'S CERTIFICATION: I certify.the materials describedabove on this manifest are,not subject to.Federal Regulations for reporting proper,disposal of hazardous waste. A F Date Printed/Ty ed'Name �� y ., Signature Month " Day Year R 17.Transporter 1 Acknowledgement of Receipt of-Materials. Cate A Printed/Typed Name N Signature Month Day Year S , R 18.Transporter 2 Acknowledgement of Receipt of Materials {. . - w Date E PrintedTyped Name Signature Month Day Year R F '19.Discrepancy Indication Space A C L 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this manifest except as noted in item 19 Date T Printed/Typed Name Signature Month Day Year Y GENERATOR'S COPY NON-HAZARDOUS 1.Generator's US EPA ID No. ` Manifest Document No. 2.,Page`i WASTE MANIFEST q a16 k of ' 3.Generator's Name and Mailing Address T A. TOWN .OF BARNSTABLE -- HEALTH DIVISION 200 MAIN STREET B.State Gen.ID . HYANNIS MA 02601 lI&9..PH1NIvEY`S "LANE _ a,Generator's Phone( ) _ EARtNSWLE XA 02630 5.Transporter 1 Company Name 6.US EPA'ID Number. C.State Trans:ID CLEAN VENTURE INC. 1.( n n. 1 I �,e 1 : �Y 7.Transporter 2 Company Name 8.US EPA ID Number TTransporter's Phone (' ) S11 E.State Trans.ID" ... _ 9.Designated Facility Name and Site Address 10.US EPA ID Number : TANK RECYCLERS (YANKEE GAS) F.Transporter's Phone.( ). 140 SOUTH MAIN STREET G.State'Facility's ID NOT REQUIRED MIDDLETON, .MA 01949 H.Facility's Phone (Q 7' ) ?77. 0 RI)11 US DOT Description(including Proper Shipping Name,Hazard Class and ID Number 12•containers „ L p ( 9 p pp 9. ) No. T e- Total Quantity wwci WASTE NO. a. XXXIMOM WASTE, PROPANE MAI99 2.1, UN1978, ERG115 G v .. _) ) s E N Y E R A T C. O R d: I J.Additional Descriptions for Materials Listed Above(include physical state and hazard code.) K.Handling Codes for Wastes Listed Above EMPTY PROPANE TANK a. C. a. C. b. d. b. d. 15.Special Handling Instructions and Additional Information CVI-O7 ORDER0 61712 24•RR. EA# 508-872• 5030 CLEAN VENTURE CVI-07 JOB# 33-264-10--67 16:GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to Federal.Regulations for reporting proper disposal of hazardous waste. ,,_ ! Date Printed d Name _ Si nature ti., Month Day Year 11 T 17.Transporter i Acknowledgement of Receipt of Materials - ""�� w Date A Pnnted/ryped Name Signature Month Day Year N !�.,.,��► S 1 R 18.Transporter 2 Acknowledgement of Re eipt of Materials0. " Date RPrinted/Typed Name Signature Month ..Day Year F 19.Discrepancy Indication Space: A • i. C L 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered by this-manifest except as noted in item 19 Date YPrinted/Typed Name Signature Month Day Year GENERATOR'S COPY a COMMONWEALTH•OF MASSACHUSETTS DEPARTMENT OFtENVIRON MENTAL PROTECTION / (% Jr��Qif.`Z!/✓ - DIVISION OF*nAZARDOUS MATERIALS One Winter Street Boston,'Mlassachu�setts 02108 +a PI se print or type.(Form designed for use on elite(1 2-pitch)typewriter) UNIFORM HAZARDOUS"... 1.Generator's US EPA ID.No. Manifest Document No. 2;.Page 1,; t Information in the shaded areas WASTE MANIFEST ` .i. of is not required by Federal law MI P 5 0 8 8 6 2 5 I + 3.Generator's Name and Mailing Address 1 r A t to Mattlf f Dbbiii lent Nutnber-, TOWN OF BARNISTABLE HEALTH DIVISION �r1'�r;'�i ,I J Q i©6�Z J 9 200 I AIN STREET ``" estate en If3 A HYANNIS, MA 02601 v. D , � aAI� 4.Generator's Phone( )fl62_ �_ � T'n60 Q CV 5.Transporter 1'Company Name 6.US EPA ID Number C O St0000 aYe Trans 1DE CLEAN VENTURE INC: � M1� O t O :3 � 0 �® � � k � rA r r 7.Transporter 2 Company Name 8.US.EPA ID Number D Transporters Phone } {} ru CV _ E SYatB Trans #D It 0 9.Designated Facility Name and Site Address 10.US EPA ID Number, O GENERAL CHERICAL CORPORATION F�Transporters 133 LELAND STREET G�Stafs Faetlify, 9 NOT REQUIRED' FRAMINGHAM, dA 01-102 H Facrlr s�Phorie �- � � 0 i�f A 7 1 Fl 7 tY... { Y) ¢ C 11.US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) 12.containers 13Un <A No. Tvpe Total Quantity w of wABTE tdQ , U a. , V ; RQ, WASTE, MERCURY 8, UN2809>f PGIII, ERGI72212, UJI R N b. STATE REGULATED OILY SOLIDS Cr qq ; r= M .T c. O z m .0 STATE REGULATED ,OILY LIQUID 0 R Z �5. m F a. Y o J 11Idttronal Descr[Ptrarts£#ur Materrals LtsYad Abova,(nckrtle tihstca}sfat®and hazard code j �K:;Hartdhng Codes for Wastes Lrsied Above` tzva- QL v. L 15.Special Handling Instructions and Additional Information O CVI--0/ ORDERIt 61712 U it:24 H EIS# 508-872 5000 . CLEAN VENTURE. f CVI -07 34D# 3 Z 3 69 >1 -t)/ c 0 0) 16.GENERATOR'S CERTIFICATION:I herebydeclare that h n a a the contents of this consignment are full* and accurate) described above b proper shipping name and are classified 9 Y Y Y P P PP 9 0 packed,marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable.international and national government regulations. If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically i practicable and that l have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human_ health and the environment;OR,if I am a small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste management N method that is available to me and that I can afford. r' t Date N Pr'ntedjTyped Name Sig ature s Month Day Year T - i 9 - .. - U 17.Transporter 1 Acknowledgement of Receipt of Materials Date . R NPrinted/Typ'e`d Name / Signature Month Day. Year P �JN 7 ✓?f' i?i q 18.Transporter 2 Acknowledgement of Receipt of Materials Date E PrintedlTyped Name - Signature Month Day Year F . 19.Discrepancy Indication Space A ). C 1 . 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by th anifest except as noted in iteml9 Date y Printed/Typed Name C ( �r Signature n y �Yea( Form Approved OMB No.2050-0 39. EPA Form 8700-22(Rev.9-99)Previous editions are obsolete. COPY>3: FACILITY MAILS TO GENERATOR INSTRUCTIONS FOR COMPLETING THE UNIFORM HAZARDOUS WASTE MANIFEST Item 1.2-,CONTAINERS(410,,&TYPE)",Enter,the.number of containers4proach waste and the appropriate abbreviations from Table I, (below}for the type of container used, IMPORTANT:READ ALL INSTRUCTIONS BEFORE COMPLETING THIS FORM _ _ _ T _ }- r,... 1._ - —�-- i._ ._.«����. �.„,«.-7 . - - -.�- -- — -TABCEf't-"CONTAINER TYPE- State and eiieral regulations require Generators,transporters,and Treatment,Stora ;and DispoTal Facilities(TS•DPs)'to use this form: t } �i ' and,if nec�!sary,jthe(Continuation Sheet.for interstate and intrastate shipmentspf h rdous wastes.+ DM=Metal drums,barrels,kegs DW=Wooden drums,barrels,kegs, DF=Fiberboard or plasticdru�ins,ltairrels, t 1 + ' - (.. TP=Tanks,portable I TT Cargo tanks(tank trucks) kegs The MA rifest co Rairis 8 copies.ACL COISIQ$MUST�E LECaIBL ! (Alegible ma�ni ests submittdd to the Stallwill be�returned to the F: rria Fx DT=Dump truck CY=Cylinders t TC=Tank cars generator 6or proper dorr}�letion.)Tl�iis for is designed'for use on a a2 pitch;(elite)typewriter.A firm ball point pen may also be used if you IT CW=Wooden boxes,cartons,cases CF=Fiber or plastic boxes,cartons,cases CM=Metal boxes,cartons,casee(ipcl. t t press down F1ARq.rEAch of the 8 copies must be filed with the"a"ppropriate party as it is completed.CcUy distribution is as follows: i - ( � roll-offs) ( , .� I COPY 1: DESTINATION STATE—:fvlailed by TSOF the on jnal!Jys with the shipment from generation to compieffon by lire TSDF. { B3=Burlap,clofkt,paper/plastic tags When the manifest is completed'therTSDFmnst mail this coptj to2he state vejTere the facilirys located: • _ t Item 13•TOTAL QUANTITY--Enter the total.quantity of waste described on each tine. F L� :, }�� J COPY 2: GENERATOR STATE—avfailed,by TSDF When the TSDF has completed his section of t e manifest,he mails-this copy to the Item 14:UNIT Wt.Nol. Enter the a ro ,late abbreviation from Yable II; below for the unit of measure used in-determiningthe,to State where the waste was generated. Y i - ,, f w... ,.�« }` r•- f t �, quantity of waste described on t(ach line.Do not use fractions.. +. ,�, +""�' •� - J U COPY 3: GENERATOR COMPLETED COPY—MailedJby TSDF:When the TSDF- as completed his section of the manifest,he mails this i } TABLE11—UNITS OFMEA RE C eopyback to the Generator of the waste,who;mu;t retain it on-site fgrhisTecoios. l i l + + , m ( - ! ! ' E f G=Gallons(quids only) L=L ters(ji0 ids onjy)( _ Pi=Pounds COPY 4: TSDF COPY:When the TSDF has completed his section of the manifest,he kelps thiscdpy or his recdtt3s. - '• ! t4 t 9 i L , L�-Tons(20 I t a� Y=CubicYards ` I + i1 K=Kilograms' Zj COPY 5: TRANSPORTER 1:Wher the transporter has co pleted his section of : nanifestggtd r`ansferred the waste tOdhe-tSOF he yq`,> ) g)_ L• N~.Cubic Meters u1-.Metric iatTs 610D0 k _ j Beeps this copy for his records. m ' T { r r i } l ] o G i T i Item I:WASY:NO.—Enter the 4 digit EPA hazardous wasi'e number as it lappears in 40 CFR Part 261,Subparts C and D.If a non-RCRA NOTE.'1f a continuing transporter is used,theige 'rator is res_pogsr ejfoC5yp tying him wi a legible photo-cop of the manifest, ^FlState-re'gulate6,'vastestream is being manifested, enter the-State waste code!here. If both the Destination and Generator States have whic�ritust contain signatures when equired. i # s s , 1 " r" .i assigned cod use the Destination-State code.If there Is-, _EPA/State-code enter one's COPY 6: DESTINATION;STATE-,Mai by nerptoif When the GeneraooF has Eompleted his sec�i{ian of the,,manifest arid-transferred his - *Item J:ADDM NAL DESCRIPTIONS FOR MATERIALS-LISTEDABOVE—Enter description;of analysis'for�apywaste ivhpli does not h3Ve *Afe io the Tra�tsporter,!ye mat this p py Wthe State where th S' noted ility(TSDF))is located ° U.S. DOT slSpping_name oi'has an N.O.S. ilesignatiprt_Enter constituent percentages, chemical names, physical?states;(S=Solid, l 1 L=Liquid,G-iGfts;SL-Sludge)and EPA Hazard Codes ignitable(1),Corrosive(C),Reactive(R), Ep Toxicity(E),Acute Haeardous;(H), COPY 7: ENERATOFT STATE-1:\Aailed by Gener2tor,:When the generafor'fias com eted his sectioY of the manifest an ransferred his 1""_ToxjFj'G__.Epter.me_spgcific gravijy t otbaLth)3.n 1,0.Any, dtJ tlonai,desired waste despription may.alsrj be,ente}�d J Bte _t. ' 1 �1 y Q? rife tp the transporter, a ma+Cs thi$copy to,the+State where thevraste was generated. I. i t J I t t i . + t Item 15: SPE�1L HANDLING(INSTRUCTIONS ND,ADDITIONAL INFORMATION—Use this space to indiY;af>'special'trari portation,-f f COPY 8: ENERATOR(When the-Generator has completed his section-of thA ma5fesi and transferred his waste to th'transporter,he treatment, stcjage(igr disposal p�Bill of Lading I formation. If an alternate facility (TSDF) is designated, note,it',here. lvr ioter`nationalJJcps this copy for his records.' } ! — —�• shiltrpen ,Ce'netatoS must enteLthe-pginfQf departthe.{City and State!from the lIS through which the waste must travel tef e e0terin a ter* r { i i t ol. 3r' �, 10. GENEfUATOR SECTION +.fioreign country.This space may also beused for emergency response telephone numbs and other information the Generator vf:ishesgox I jl I t ;, t t t include aboutf¢e shipment,including placarding. y 1' '`Item 1:GSzNERATOR'$`U5 EPA ID MANIFEST DOCUN J NO---Enteethe US EPA generators 12 digit identification number.Then`' * i i t;+ ) !, C ' L enter a un ue,5 i it umber you assign to this manifest.Use dsgnall mi:reasrn f 0i nbers a 00001,00002„etc'., is recommended. Item K:HAND NG CODES—TSDF Completes this section—See"De gnated Facility Section"(below). r rja rf 9 Y 9 - Y 9' ( 9 ) i 6 X_ %, jE ! j i r+ .` '( �°`fern 2: P¢(GE}J�of T — EAT the Lail number' {ages used to hmplete this manifest, i!e., the firpt:form plus-thi rcamber of.�.�ltetp�¢:,•G�[y�t�FITQB�CE�tTjFIC/�JON�Th�Getierator must read,sign (bjq hand)and date the certification(wdF7 e of transferjo ontinuatipn Sheets,'fang.Any EPA approve continuation she,etmay be used,tiut,di'stribution and completidrr"must meet Massachusetts transporter).If a made other then highway is used,the word"highway should'be lined out and the appropriate mode rail,v,ater or`:air) jynanifest r$quirements.p t i t i?`-t { inserted in the space.',below.If another mode in addition to the highway mode's used,enter the appropriate mode(eg "and rail�+n`t6e- { ( t e r; fi t i 7 t space below.iIn signing the waste minimization certification staterrte Llhose gene,.,en who have not been exempied by s(�tut;�or_r U'item A:*ATE MANIFEST DOCU;N•n•ENT NU ER Nu Ter preprinted�by_MA=.e=x.ae t oruthe Continuation+Sheets:Ent fr this number m regulation frorti the duty to make a waste minimizatign certification uncle section�3Q02(b'Of RCRA are also certify n that they have cgmp i d j . item Lon Each C ntm�ation Sheet fittached to or part of a nifesf- { { yi } with the wast6 minimization regUirements. Ij } - 3 { I k f r,•,.• j t i- c.f t !l •w,.' (item 3:GENERATOR'9AAME AND.MAl),t,IfJG ADDRESS— nter,ffie name(as.noti led to EPA)and mailing adddress of the Generator.This ,,r f { TRANSPORTER SECTION- 'address shouldtf the•location that?will rfianage the re'in manifest forms :. + `•:+ , S l t 't, 3 1"•-', ' C f ' .. Item 17:TRANSPORTER 1 ACKNOWLEDGEMENT! Print or type the name+of.the;person accepting the Ste on behalf of_le'first p t itern 4:GENERATOR'S.�P}10NE NUMBER'—Ente_r a telephone iaarnber wift&rea cg8e where an aulyiorized agent of;he-Generator can bet , Transporter.That person must acknowledge acce ®once of the waste de cribeo on the r45kfest by signing and entering the dati.of�d p Treached in ann emer erc ;`~`' t � t 1 y + - r' r= `` `l 2 t 9 Y t ' i t < 1 ti( �; I Item 18:TRANSPORTER 2 ACK�OWLEDGEMEN � applicable,follgw the insttuctionsfor Item 17 for Transportrter 2. o *Item B:STATE EN Ili t The State GeSerator ID is the sreet address of 9e Generators`pick-up location.If`the malhcYgaddress and the j ` 1.~ o- DESIGNATED FACILITY c)+ ,street addrIess are the Sane,enter siaame"n this block.f S + �' , l (TSDF iSECTION r {yj -' � N 1 1 f y� Item K:HANDLING CODES:TSDFtSHOULD COMPLETE—Enter the ultimate handlin ethod utilized at thwolesi n ry J `[tem 5:T+NSP(!)RTER t COMPA Y NAME—Enter a comps nameq nbtifiep to EPA)of the first transporter wh will transport the gin gated facility or each rite. tt 1 t t Y ' ?o l i '' waste listed irr Item 11.Only theifollowing process Bodes may be used: i Cam` 'tem 6:US EPA J Number—Enter the U EPA 12 dlgi identification numbee oEthe first transporter_idelttified in Item 5, } t j S TABLE I II,-.PROC!ESS CODES * l ! V+ i u FF ---=t^�- t STOflAGE $01(Contain ) S02(rarJft { S03(Wa{te Raj i SJ4(Surf Impountlmenl) sits tONe, pecdy) n,ltem C:STATE TRAN`ID—Enterithe Staf$of'reglstratton rid the ficens1plaie member of the wife-carryin portronof ifie vehicle being 1 # I ; rlsedtom keYhe` ick-u i t �' TREATMENTAfert,40CFR pan I.ApQen IT.W.2. P P I E c' 4 DISPOSAL Drsa";dw 1) Deana mo( .D(n(arlApp4icat« oaz(o o:per) shwa elmpl) Item;D: RANSPORT.Et3'S PHONE—Enterla telephone tTumber with;area Bodo where an authorized agent of the transporter can be t OM tott,w Speoty) �r f C;eached i, i yy !" / 1 i rr F k j i r i i- �, i . { 1 r! t - a r a. `•t Item 19:DISCREPANCY INDICA ION SPACE—T a authorized representative ofthe designated facility's owner or operator must note ip this Rem T TRANSPORTER 2 COMPANY NAnpE� ;if appliciabf enter t1ie companAameTlas notified to,JLIP)of the second transporter who will s ace,an si ificant discrepant between the waste described on t anifest`nd the aste actual) received at.the'fadifi An re acted a (� , P Y 1n Y f t e W Y c Y 1 transport the waste.If more than ty o IT po tier will be;u�ed,use a Continuation Sheet and list he transportf?ra in the�grder they will be I materials should be listed here,along with an indication of the disposi�dp of the rojected materials.Any applicable Discrepancy or Exception trans rtin the waste'{ i # l } J -^ t t 1 reporting req"rements must also be com lied wit�.Tederal and State regulations va r g i t ! t P q l: 09 Y rY t Item 8:,UIEPA If?NUMBER—If applicabj e�ter the S E A 12 digit identification nurrther of the transporter in item 7- + Item 20:FACILITY OWNER OR(OPERATOR,CERTIFICATION PrintQ�type the name of[he person accept(Tg the waste on behalf�f the t ,l i1' ( i ! 1 l r% '- " i t owner or opefator of the designated TSDF.+That person must acknowledge acceptance of the waste-described on the manifest by signing *femTE STATE TRANYD,—If applicable, at,the second transpdrter's"Sta1e of registration and license plate number for the waste carrying t t r-, (by hand)anrtentering the date of receipt.The signature of the authorjked TSDF agent hjr�cates acceptance�b_f(except for',items specified in portion of t#ielv"icle bai6g usedf make tie{lick •p t t .+ c ! r f t t s t _ 1 Item 19)and agreement with statements on this ma{ife'st. +i r 1. i - *ItemT--RWNSF ORT&S PHONi —If applicable,erpn the secpKcf trarisportees telephone numbec.with area code where an authorized agen rtof231%e trap orter n be rea hed. z j~ j f s w 4 d? u f NOTE;FOR INTERSTATE SHIPMENT YOU MAY IBI <EQUIRED TO'COMPLY Vtl1T1i SHE MANIFESTING RET]�JIRFMENTS b 1 QTH.Ff E 0 y - f! DESTINATION AND GENERATOR STATt$gEGARDilIG THE COMPLETION OF SPECIFIC INFORMATION INCLUDED Item 9.DESIGN TED FA ILITY NAME AN6-SITE ADDREEjS—Enter the'cpmpapyen me(as notified to EPA)of the TSDF designated to A-K. - I l a , ` ' w receivg jha was)eflisted on this rilanifesL°1�iB a dress,,lust ae the site address rvvhich,hay differ from link address. r ( r f r r a t 1 .- }} f `�u cF r+t ( -BURDEN STATEMENT The public reporting burden fpr this collection"of information ikestimated to averagebt,minutes l&-gererators,le Item t `fJS EPA ID NUMBER—`Eater t#tQrllrS Ed 12I1gIt iAenttfication numbetof th8designated_TSDF listed id1 item 9, w i minutes for tnsporters,and 1'6 minutes for treattn�tt,storage and,>disposal,tgcilities,7fte recordkeepmg brirden per Irppnse fQr-this ' s j ( I t ' y collection of Information is estimated to average 6!nt utes for gener���s,6 mirfutes for [ansporters,and 6 mijin6s for treatment,stClige *Item137gATE FACILU('S ID No ant IgY,rPtqu`fr' yjk&p5sau�tit,setts, a J -' t and disposal I cilities.The burden associated with re4iding the re ul$f©ns is estimatedra fit,hour and 15 miriufe5�dnr'St'ial Burden means 11 ii t. -c -T t {• P 9 IY *Item H FACILITY PHONE—Eriter a tele Kona rtum5er with area code forih6 TSDF jesignated to�ei clue the yvaste listed on the manifest. The total Yime,leffort,or financial,resources e.pended by persons'to gertierate,m intaln retain,6f disclose or prg4h info ation Wor*for a f e t f ) c T`' _ try ( Federal agency. ell i „l { _ i �' , Item 1y US DOT DESC411PTION:,All of'the foltowirtgirriL+t bag feredi 1jTe corrgcf U DOT(Depr�tment of Transportation)name for the t waste,,-as dent fled in 4y{CFR Pants 171-177(usually foup in..a�umn 2 of section.77�.101),thedi6signed TT H62ard t3lass(usually in'" An agency m y not conduct or sponsor,and a p ,son is not required'to respond to,a collect on of informaton rin s t dish ayS r jM y k column-3)and t o 4 digit UN/NA 1D nu ber(column 9A (e.gAWaste Sulphuric acid,spent,co We material,UN1832RQ). US DOT valid OMB m�trol number.Tttd OMB numbers fdr�F�A's regulations are listed-in 40 CFR Part 9 and 48 CFR)CIn;pter.t5:0end commeofs _ _- requires the word_"waste,bBfyor yorin the§' In-g name,for+all Fazard'ous waste. `- -r'�gardujg-these iSiirrion stit_at€me ss oT-•Eny otheTt9j5ecf of this ICMectioh,Including sug-g4 ions`thf reducir g the Uui'den-,jncludin ffirough the tisa of butonrtfteC7Collection'-techniques to the Director,OPPE Regulatory Information Division,U.S.Environmental Protection Agency -"" �,,,,, �•;l i„ "',2137)`4Qt;I` , -SW�,Wa�YfIJ gY "P C,,z04J30"aftd t).tfie'C)ifc2; .ifAQYFnatibh,`antl Fi tiiatory"Affail`s,IOlfi�r*SfMandgement and Byidget, ll C 2 + t+l �iJ '-C� + ., t7 �' + 1I J.t r f� t�f� ,j`1t !gtt�ritidr(:f3eb O�ficer6.EPAT�7d %-lr'e( k1.W Khingtom,D.C.26!03.Inctiirla th6OMB control number in any correspondence. i , GENERAL CHEMICAL CORP. fRRMINGRRN 138 LELAND SL ►��,'� MR 01707 ** FRAMINGHAM, MA 01702 9!!P $0.390 $0,390 * l Jill IIoilfil111.11111m111��11.�1�a,�'1'1,� 1,1111,I1rL11a�11111 tt ttt tt ttt ttt t } t t tit t t !I, ! Hilt / r 'y. At. • r r� Clean Venture/Cycle Qfvem' •LABP K PACKING LIST GENERATOR: ' —W`f D.O.T. PR PER SHIPPING NAME: a G. 7 b. �:Qv �e Ie A1lr�t � (G� A/sDLx� L S'ate HAZARD CLASS: , C'/%/,,NA: A-B//t/Q�BILL TO: PACKING GROUP: RQ CONTACT: CCI REP: STATE-CODES: circle all that apply-S Iwo C Tr I C He R EPA CODES: d t ., EPA ID#: MANIF EST#: SPECIAL DISPOSAL REQUIREMENTS: 'NONE t DRUM#: CONTAINER SIZ YPE• [6 ONO LANDFILL' ' INCINERATION.ONLY ` Page of DATE: a�l� C DOTHER: e � CCI APPROVALS (to be filled in by C.CL).:,_..,_-- APPROVAL CODE: ROW#: PRICE: MINIMUM: DOT HAZ: STATE HAZ: _ 9 DESCRIPTION OF MATERIALS-HAZARDOUS SUBSTANCE CONTAINER PHYSICAL . EPA QUANTITY (NO TRADE NAMES) ,,» TYPE STATE'. CODES . . ! Pad IN Ir a 06,1,A+ Emo/C-V�q iff"I IRS 'L Total Weight( 1 gal. =8 lbs.) Packaged By: 'yf.v Print Name Signature hab2/13/01 _ l Clean Venture/Cycle C'if�em, (LA' 13PACK PACKING LIST 70- E GENERATOR: D.O.T. PROPER SHIPPING NAME: ►�.Ca{. , tS1 ` R "e-... .. .. I UN - A: � 1� C�1►S 'C/Gy�jC ,� �. HAZARD CLASS: BILL TO: �'� PACKING GROUP i RQ: rr: CCI REP: STATE CODES: circle all that apply-S L C T I :C H E R CONTACT: ; �� EPA CODES: P601 EPA ID#: MANIFEST#: SPECIAL DISPOSAL REQUIREMENTS: ❑ NONE DRUM#: CONTAINER SIZE/TYPE: QNO,LANDFJLL INCINERATION ONLY ` Page ) of t DATE: ❑OTHER: { f CC APPROVALS (to be filled in by CCI): APPROVAL CODE: ROW#: PRICE: MINIMUM: DOT HAZ: STATE HAZ:- w DESCRIPTION OF MATERIALS—HAZARDOUS SUBSTANCE CONTAINER PHYSICAL EPA QUANTITY (NO TRADE NAMES) TYPE STATE ,,CODES AAA Total Weight( 1 gal. =8 Ibs,) Packaged By: r 1, (A A �0 Print Name Signature hab2/13/01 Fla LLlb CCycle Chem, Inc. General Chemical Material Profile Sheet 217 South 1 st St. 550 Industrial Dr. Cto r p o r a t i o n GencodelGen#: Stream:(if applicable) Elizabeth,NJ 07206 Lewisberry,PA 17339 _ Phone:(908)355-5800 Phone:(717)938-4700 133-138 Leland St.,Framingham, MA 01701 www.cyclechem.com Fax:(908)355-0562 Fax:(717)938-3301 Phone:(508)872-5000 Fax:(508)875-5271 process/Product Cod GENERATOR INFORMATION EPA ID# BILLING COMPANY Cv GENERATOR NAME !!'WIN 6f ,kr- m o ,c,dA BILLING ADDRESS r MAILING ADDRESS BILLING CONTACT ' GENERATOR CONTACT P BILLING PHONE# 0 FAX GENERATOR PHONE# NAMEOFWASTE: ` GENERATOR FAX q N— 36,-y ti SITE ADDRESS l�h Q ' PROCESS GENERATING WASTE: B.PHYSICAL CHARACTERISTICS OF WASTE(AT 700 F) , LiquidlSolidlSlud D.REGULATORY INFORMATION ae I Color/Odor/ Is it USEPA Haz waste? Physical Description: I%Liquid Yes Q No %Suspended Solids USEPA Haz Codes: Wastewater: %Sludge EPA Sub Categories: O Wastewater l�Non-wastewater >a Specific Gravity: %Solid fi6 i Is it STATE waste? Yes Q No Physical State: g �1���,,,,,,,,CCCCC))))) Dumpable? 0Yes 0 No I STATE Haz Codes: Y ❑Single Phase ❑Solid L a Packsol i Pumpable? O Yes No ❑Bi•Layered ❑Liquid Lab Pack ❑Multi-Layered ❑Semi-Solid I Pourable? O Yes 1po DOT Hazardous Material?07YeS Q NO ❑Powder ❑Sludge "' — -- — Proper Shipping Name: WcA5f_ae-10'SS S Flash Point: O Flash Point<74 F 0 Flash Point 101.140 F O Flash Point>200 F 0 Exact Flash Point: Flash Point 74.100 F O Flash Point 141-200 F O No Flash Point O Open cup O Closed cup Hazard Class: NI A#: �P.G,; Ignitable Solid? 0Yes 0No RQ: ERG#: pH: O<2.0 0 2.01-5.0 .01.9.0 0 9,01.12.49 0>12.5 O ExaclpH E. SHIPPING INFORMATION C, CHEMICAL COMPOSITION Shipment Method: ATTACHMENTS: ❑MSDS attained ❑Bulk Liquid•Tanker ❑1 lwis) rum(Size): X S'j ❑Supplemental Analysis ❑Addilonal Information ❑LDR Attachment ❑Bulk Solid•Omp Tlr El Tote(s) ChemicalComoosition Percent Minimum Maximum ❑Bulk Solid•Roll Off ❑Cubic YardBoz(s) ❑Other(Size): Anticipated Volume:_ 1[7� per Am� fo ° �uhs oC— Quantity:_ Price• 1 Unit• F. SPECIAL HANDLING CONSIDERATIONS ❑Radioactive ❑PA RW SQG ❑No Land Filling ❑EtiologiclMedical Waste ❑DRMS/DRMO Waste ❑Incinerate Only 6 Q at ❑Fuming ❑CERCLA Waste ❑Recycle Only ❑Phenolics [IAsbestos ❑Other: G. TRANSPORTER ARRANGEMENTS OCCIIGCC Provides Transportation O Other, O Customer Delivers to CCIIGCC Indicate if waste contains any of the following: O Customer Delivers to End Facility via CCIIGCC Non•Rea. or LessThan or Actual H. OTHER HAZARDOUS CHARACTERISTICS Cyanides ❑ 250 P M ❑RCRA REACTIVE ❑ETIOLOGICAL ❑EXPLOSIVEISHOCK SENSITIVE Phenolics ❑ 50 PPM ❑WATER REACTIVE ❑TSCA REG ❑NONE OF THE ABOVE Sulfides ❑ 500 PPM ❑RADIOACTIVE ❑OXIDIZING MAT L vocs ❑ SOOPPM ❑SUBJECT TO SUBPART FF BENZENE REG ❑PYROPHORIC Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined In 40 CFR 268 Part 2, through D040)? O Yes*No Section I at concentrations exceeding the UTS treatment standards? 0 Yes 0 No If YES,please list the constituents and concentrations in section C. If YES,please list the constituents and concentrations in section C. GENERATOR CERTIFICATION:I hereby certify that all Information submitted In this and all other attached documents is complete,contains true and accurate descriptions and is representative of the waste material,and that all relevant Information regarding known or suspected hazards In the possession of the generator has been disclosed.If CCIIGCC discovers,after having taken the delivery of the waste,that any waste does not conform to the Identification or descriptions contained In this MPS then CCIIGCC shall provide notice to Generator and coordinate the return,If applicable,of the non conforming waste to the point of origin as set forth In the manifest or to such other locations designated In writing by the Generator.Generator agrees to reimburse CCIIGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCNGCC during the receipt,handling,temporary storage and return of such non conforming waste to Its point of origin or to such other location designated by the Generator.I hereby authorize CCIIGCC to amend and/or correct any Information on the MPS with the full understanding that if any amendment or correction is performed,I will be contacted as such to issue any approval. Authorized Signature Title Date CCIIGCC I Sales Code Residual Waste/ APPROVAL Tech Initials Date Management Initials Date Form code: r Cycle Chem, Inc. General Chemical Material Profile Sheet C 217 South 1st St. 550 Industrial Dr. Oorporatlon Gencode/Gen M Stream:(if applicable) Elizabeth,NJ 07206 Lewisberry,PA 17339 UTPhone:(908)355-5800 Phone:(717)938-4700 133-138 Leland St.,Framingham, MA 01701 www.cyclechem.com Fax:(908)355-0562 Fax:(717)938-3301 Phone:(508)872-5000 Fax:(508)875-5271 process/Product Code: mitmommwi A.GENERATOR INFORMATION EPA ID# BILLING COMPANY CV — GENERATOR NAME (^ rYk -C j r1.rk -- C �L ,aA BILLING ADDRESS e r MAILING ADDRESS S .te P —1)12`— BILLING CONTACT ` GENERATOR CONTACT [� BILLING PHONE,# 0 FAX GENERATORPHONE# "GENERATOR FAX NAME OF WASTE: 6 r } SITE ADDRESS lrh PROCESS GENERATING WASTE: QA ✓ltr3 p/` B.PHYSICAL CHARA TERISTICS OF WASTE(AT 70o F) ;-- ----., D.REGULATORY INFORMATION LiguidlSolidiSludge I Color/Odor/ I%Liquid is it USEPA Haz waste? Q Yes NO Physical Description: q �— %Suspended Solids USEPA Haz Codes: Wastewater: 0 Wastewater tt6DNon-wastewater %Sludge EPA Sub Categories: %Solid 108 Specific Gravity: I Is it STATE waste? Yes Q No Physical State: Dum able? STATE Haz Codes: Y � ❑Single Phase Solid ❑GaslAerosol i pumpable? O Yes �No i ❑MuBi-lti-Layayeredered ❑Liquid ❑Lab Pack pourable? �j DOT Hazardous Material? Q Yes bNO ❑Multi-La ered ❑Semi-Solid I O Yes No ❑Powder ❑Sludge -• ---- ' Proper Shipping Name: Q Flash Point: 0 Flash Point<74 F O Flash Point 101.140 F JWFlash Point>200 F 0 Exact Flash Point: O Flash Point 74.100 F O Flash Point 141-200 F O No Flash Point Hazard Class: UNiNA#: 0 Open cup O Closed cup P.G•: Ignitable Solid? O Yes V No RQ: ERG#: PH: 0<2.0 O 2.01-5.0 05.01.9.0 0 9.01.12.49 O>12.5 0 ExaclpH E. SHIPPING INFORMATION C. CHEMICAL COMPOSITION ol�sfee� d'h�a5 Shipment Method: f ATTACHMENTS: ❑MSDS attached ❑Supplemental Analysis ❑Additonal information ❑Bulk Liquid•Tanker ❑Tote(Pallets) Drum(Size): PP Y ❑LDR Attachment ❑Bulk Solid•Dmp Tlr ❑Tote(s) ChemicalComoosition Percent Minimum Maximum ❑Bulk Solid•Roll Off ❑Cubic YardBox(s) ❑Olher(Size): I Anticipated Volume: 300* Per 1 ,, Quantity: Price: /Unit: 0 Ls F. SPECIAL HANDLING CONSIDERATIONS ❑Radioactive ❑ PA RW SQG ❑No Land Filling �. ❑Etiologic/Medical Waste ❑DRMSIDRMO Waste ❑Incinerate Only C [I Fuming ❑CERCLA Waste El Recycle Only --� ❑Phenolics ❑Asbestos ❑Other: G. TRANSPORTER ARRANGEMENTS CC Cl/GCC Provides Transportation O Other: ustomer Delivers to CCl/GCC Indicate if waste contains any of the following: O Customer Delivers to End Facility via CCIIGCC PCB Non-Reg. orLessThan or Actual H. OTHER HAZARDOUS CHARACTERISTICS Cyaanides ❑ 250PPM ❑RCRAREACTIVE ❑ETIOLOGICAL ❑ Phenolics EXPLO5IVEISHOCKSENSITIVE ❑ 50 PPM ❑WATER REACTIVE ❑TSCA REG 4PONE OF THE ABOVE Sulfides ❑ Soo PPM ❑RADIOACTIVE ❑OXIDIZING MAIL VOCs ❑ 500PPM ❑SUBJECT TO SUBPARTFF BENZENE REG ❑PYROPHORIC Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined In 40 CFR 268 Part 2, through D043)? O Yes f jNo Section I at concentrations exceeding the UTS treatment standards? O Yes Vo If YES,please listlhe constRulrnts and concentrations in section C. If YES,please list the constituents and concentrations in section C. GENERATOR CERTIFICATION:I hereby certify that all Information submitted In this and all other attached documents Is complete,contains true and accurate descriptions and Is representative of the waste material,and that all relevant Information regarding known or suspected hazards In the possession of the generator has been disclosed.11 CCIIGCC discover.,after having taken the delivery of the waste,that any waste does not conform to the Identification or descriptions contained In this MPS then CCIIGCC shall provide notice to Generator and coordinate the return,If applicable,of the non conforming waste to the point of origin as set forth In the manifest or to such other locations designated in writing by the Generator.Generator agrees to reimburse CCIIGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCIIGCC during the receipt,handling,temporary storage and return of such nonconforming waste to its point of origin er to such other location designated by the Generator.I hereby authorize CCIIGCC to amend andlor correct any Inlorma Ion the MPS with the full understanding that if any amendment or correction Is performed,I will be contacted as such to Issue any approval. Authorized Signature Title Date CCIIGCC Sales Code APPROVAL Techlnitials Date-2 �t Management Form ode:al Wastel g Date Form code: Cycle Chem, Inc. General .Chemical Material Profile Sheet 217 South 1 st St. 550 Industrial Dr. Corporation Gencode/Gen M Stream:(if applicable) Elizabeth,NJ 07206 Lewisberry,PA 17339 Phone:(908)355-5800 Phone:(717)938-4700 133-138 Leland St.,Framingham, MA 01701 www.cyclechem.com Fax:(908)355-0562 Fax:(717)938-3301 Phone:(508)872-5000 Fax:(508)875-5271 process/ProductCode: GENERATOR INFORMATION JEPA ID# '` BILLING COMPANY CV GENERATOR NAME !(,Lott et, 81krhs M. p —Y}ea} c�t�I/,1i,6A BILLING ADDRESS r MAILING ADDRESS oZ`!)t� S .re BILLING CONTACT GENERATOR CONTACT P BILLING PHONE It 0 FAX GENERATORPHONE# NAME OF WASTE: GENERATOR FAX — L 361101.t• SITE ADDRESS lrh e - PROCESS GENERATING WASTE: B.PHYSICAL CHARACT RISTICS OF AASTE(AT 70e F) — 7Solids _ D.REGULATORY INFORMATION Liquid/SColor/Odor/ Is itUSEPAHazwaste? QYes 0 Physical Description: e%LiquidUSEPA Haz Codes: /e SuspendeWastewater: 0 Wastewater ONon-wastewater %SludgeEPA Sub Categories: Specific Gravity: %Solid Is it STATE waste? ( Yes Q NO Physical State: ❑Single Phase ❑Solid ❑Gas/Aerosol Dumpable? Yes O No I STATE Haz Codes: ❑ I Pumpable? Yes 0 No 8i-Layered Liquid ❑Lab Pack � ' ❑Mulh-Layered 4:1 Semi-Solid I Pourable? Yes 0 No I DOT Hazardous Material?Q Yes No A ❑Powder ❑Sludge — - f Proper Shipping Name: S' 2 I Flash Point: 0 Flash Point<74 F 0 Flash Point 101-140 F Flash Point>200 F 0 Exact Flash Point: 0 Flash Point 74.100 F .0 Flash Point 141-200 F 9No Flash Point Hazard Class: UNINA#: P.G.: O Open cup O Closed cup Ignitable Solid? QYes (*No RO: ERG#: pH: O<2.o O 2.01-5.0 05.01.9.0 0 9.01-12.49 0>12.5 0 ExactpH E. SHIPPING INFORMATION C. CHEMICAL COMPOSITION Shipment Method: 1'Ord s � ❑Bulk Liquid•Tanker ❑Pa lefts) iprum(Size): /- x ATTACHMENTS: ❑MSDS attached [I Supplemental Analysis ❑AddilonalInformation ❑LDRAttachment ❑BulkSolid-DmpTlr [ITote(s) Chemical Composition Percent Minimum Maximum ❑Bulk Solid•Roll Off ❑Cubic Yard Boils) ❑Other(Slze): Anticipated Volume: Per ,)- r DI Quantity: Price: 1 Unit F. SPECIAL HANDLING CONSIDERATIONS ❑Radioactive ❑PA RW SOG ❑No Land Filling 44 ❑Etiologic/Medical Waste ❑DRMSIDRMO Waste ❑Incinerate Only ❑Fuming ❑CERCLA Waste ❑Recycle Only Phenolics ❑Asbestos ❑Other: G. TRANSPORTER ARRANGEMENTS (OCCl/GCC Provides Transportation O Other. O Customer Delivers to CCl/GCC Indicate if waste contains any of the following: O Customer Delivers to End Facility via CCl/GCC Non-Rea, orLessThan or ActuaPca l H. OTHER HAZARDOUS CHARACTERISTICS Cynides o 290P M Phenolics 50 PPM ❑WATER REACTIVE ❑ETIOLOGICAL ❑NONEXPE THE ABOVE SENSITIVE Sulfides ❑ 50o PPM ❑RADIOACTIVE ❑TSCA REG �JNONE OF THE ABOVE ❑OXIDIZING MAIL rr-- VOCs ❑ SOOPPM ❑SUBJECT TO SUBPART FF BENZENE REG ❑PYROPHORIC, Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined in 40 CFR 268 Part 2, through 0047)? 0 Yes ITb No Section I at concentrations exceeding the UTS treatment standards? 0 Yes &No If YES,please list the constituents and concentrations in section C. If YES,please list the constituents and concentrations in section C. GENERATOR CERTIFICATION:I hereby certify that all information submitted In this and all other attached documents Is complete,contains true and accurate descriptions and is representative of the waste material,and that all relevant Information regarding known or suspected hazards In the possession of the generator has been disclosed.If CCIIGCC discovers,after having taken the deflvery of the waste,that any waste does not conform to the Identification or descriptions contained In this MPS then CCIIGCC shall provide notice to Generator and coordinate the return,if applicable,of the non conforming waste to the point of origin as set forth In the manifest or to such other locations designated in writing by the Generator.Generator agrees to reimburse CCIIGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCIIGCC during the receipt,handling,temporary storage and return of such non conforming waste to Its point of origin or to such other location designated by the Generator.I hereby authorize CCIIGCC to amend and/or correct any Information on the MPS with the full understanding that if any amendment or correction Is performed,I will be contacted as such to Issue any approval. Authorized Signature�1 Title Date CCIIGCC Sales Code Residual Waste I APPROVAL Tech Initials_z&Date Management initials Date Form code: Cycle Chem, Inc. General Chemical Material Profile sheet cm 217 South 1 st St. 550 Industrial Dr. Corporation Gencode/Gen#: Stream:(if applicable) Elizabeth,NJ 07206 Lewisberry,PA 17339 133-138 Leland St.,Framingham, MA 01701 Phone:(908)355-5800 Phone:(717)938 4700 Phone: L land S.,Framingham, ingha 08)8A 0171 www.cyciechem.com Fax:(908)35570562 Fax:(717)938-3301 ,. Process/Product Coder GENERATOR INFORMATION EPA ID# BILLING COMPANY Cv GENERATOR NAME (" t� �� �rr.rhS —� tc--tu_I'�I� BILLING ADDRESS r MAILING ADDRESS S .re BILLING CONTACT GENERATOR CONTACT P BILLING PHONE# o FAX GENERATOR PHONE# NAME OF WASTE: GENERATOR FAX �G SITE ADDRESS lrh PROCESS GENERATING B.PHYSICAL CHARACTERISTICS OF WASTE(AT 70°F) — -- D.REGULATORY INFORMATION Color/Odor/ ,, S ; Liquid/Solid/Sludge 1 a.(�� Is it USEPA Haz waste? O Yes NO Physical Description: I e%Liquid --- USEPA HazCodes: /s Suspended Solids I %Sludge EPA Sub Categories: Wastewater: O Wastewater Non-wastewater �(^ Specific Gravity: %Solid i Is it STATE waste? O Yes (P No Dum able? STATE Haz Codes: Physical State: ❑Single Phase Solid ❑Gas/Aerosol p Yes O No m All ❑Bi-Layered 1p Liquid Pumpable? O Yes ®No Lab Pack Pourable? DOT Hazardous Material?J0 Yes O NO ❑Multi-Layered ❑Semi-Solid � O Yes �No , ❑Powder ❑Sludge ------ — i Proper Shipping Name: t+krrt'_S %�VQ+. r 4jiu— Flash Point: O Flash Point<74 F O Flash Point 101.140 F Q Flash Point>200 F O Exact Flash Point: O Flash Point 74.100 F O Flash Point 141-200 F D No Flash Point � Hazard Class: (UNyNA#: 2 _P.G.: — O Open cup.O Closed cup u Ignitable Solid? O Yes 11�No RQ: ERG#: pH: <2.0 O 2.01-5.0 O 5.01.9.0 O 9.01-12.49 0>12.5 O Exact pH E. SHIPPING INFORMATION C. CHEMICAL COMPOSITION Shipment Method: ,�/ �� ❑Bulk Liquid•Tanker ❑Tote(s) 6r Drum(Si:c): ATTACHMENTS: ❑MSDsattached ❑Supplemental Analysis ❑Additonalinformation ❑LDRAttachment ❑Bulk Liquid-olid- Tanker ❑Tallet( Chemical Composition Percent Minimum Maximum ❑Bulk Solid-Roll Off ❑Cubic YardBox(s) ❑Other(Size): Anticipated Volume: v # Per Quantity: Price: 1 Unit• r c I F. SPECIAL HANDLING CONSIDERATIONS ❑Radioactive ❑PA RW SQG ❑No Land Filling ❑Etiologic/Medical Waste ❑DRMSIDRMO Waste ❑Incinerate Only �r'uaS Z y� ❑Fuming ❑CERCLA Waste ❑Recycle Only 11 ❑Phenolics ❑Asbestos ❑Other. G. TRANSPORTER ARRANGEMENTS 9CCIIGCC Provides Transportation O Other. O Customer Delivers to CCl/GCC Indicate if waste contains any of the following: O Customer Delivers to End Facility via CCl/GCC Non-Rea. or LessThan or Actual H. OTHER HAZARDOUS CHARACTERISTICS PCBs ❑ SOPPM Cyanides ❑ 250 PPM ❑RCRA REACTIVE ❑ETIOLOGICAL ❑EXPLOSIVEISHOCK SENSITIVE Phenolics ❑ SO PPM ❑WATER REACTIVE ❑TSCA REG NONE OF THE ABOVE Sulfides ❑ 500 PPM ❑RADIOACTIVE ❑OXIDIZING MArL VOcs ❑ SOOPPM ❑SUBJECT TO SUBPART FF BENZENE REG ❑PYROPHORIC Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined In 40 CFR 268 Part 2, through 0043)7 O Yes No Section I at concentrations exceeding the UTS treatment standards? O Yes 6 No 11 YES,please list the consti tents and concentrations in section C. If YES,please list the constituents and concentrations in section C. GENERATOR CERTIFICATION:I hereby certify that all Information submitted In this and all other attached documents Is complete,contains true and accurate descriptions and is representative of the waste matedal,and that all relevant information regarding known or suspected hazards In the possession of the generator has been disclosed.If CCUGCC discovers,after having taken the delivery of the waste,that any waste does not conform to the identification or descriptions contained In this MPS then CCIIGCC shall provide notice to Generator and coordinate the return,If applicable,of the non conforming waste to the point of origin as set forth In the manifest or to such other locations designated in writing by the Generator.Generator agrees to reimburse CCIIGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCUGCC during the receipt,handling,temporary storage and return of such non conforming waste to Its point of origin or to such other location designated by the Generator.I hereby authorize CCIIGCC to amend andlor correct any Information on the MPS with the full understanding that If any amendment or correction Is performed,I will be contacted as such to issue any approval. Authorized Signature lb Title Date CCUGCC Sales Code Residual Waster APPROVAL Tech Initials Date 7 Management Initials Date Form Code: I ca Cycle Chem, Inc. General Chemical Material Profile sheet 217 South 1 st St. 550 Industrial Dr. C`O r p o r a t i o n Gencode/Gen M Stream:(if applicable) Elizabeth,NJ 07206 Lewisberry,PA 17339 _ Phone:(908)355-5800 1.Phone:(717)938-4700 133-138 Leland St.,Framingham, MA 01701 www.cyclechem.com Fax:(908)355-0562 Fax:(717)938-3301 Phone:(508)872-5000 Fax:(508)875-5271 process/Product Code. GENERATOR INFORMATION EPA ID# BILLING COMPANY CUB GENERATOR NAME l^l.�h r'� rk.r hn lslo C �1/►7/) , BILLING ADDRESS Le feo MAILING ADDRESS a0 -S-frelpl- 14u,. `"`1— BILLING CONTACT GENERATOR CONTACT P BILLING PHONE# o FAX GENERATOR PHONE# NAME Of WASTE: Lofty- n GENERATOR FAX Q �y- f a I \ts SITE ADDRESS 417 PROCESS GENERATING WASTE: B.PHYSICAL CHARACTERISTICS OF WASTE(AT 70"F) ;— -- D.REGULATORY INFORMATION LiouidlSolidlSludae I Color/Odor/ I Is it USEPA Haz waste? Q Yes NO Physical Description: I%Liquid %Suspended Solids i USEPA Haz Codes: Wastewater: O Wastewater #Non-wastewaler %Sludge EPA Sub Categories: Specific Gravity: D Solid I is it STATE waste? Q Yes (*No Dum able? 6j I STATE Haz Codes:Physical State: ❑Single Phase ❑Solid ❑Gas/Aerosol Dump able? Yes �O No j n/111s I Pumpable? O Yes ❑Bi-Layered ❑Liquid PLab Pack DOT Hazardous Material? ❑Mulli-Layered ❑Semi-Solid j Pourable. O Yes �No Q Yes NO ❑Powder ❑Sludge ----- - Proper Shipping Name: ov l7 ti. Flash Point: O Flash Point<74 F O Flash Point 101-140 F lash Point>200 F O Exact Flash Point: Ih• o� O flash Point 74.10O F O Flash Point 141-200 F O No Flash Point Hazard Class: UNINA#. O Open cup O Closed cup P.G.: Ignitable Solid? O Yes 07No RQ: ERG#: P H: o<2.0 0 2:01-5.0 .01-s.o 09.0,.,2.a9 0>12.s O Exact pH E. SHIPPING INFORMATION C. CHEMICAL COMPOSITION oµSTeef Shipment Method: xs5' ATTACHMENTS: ❑MSDS attached ❑Supplemental Analysis ❑AddilonalInformation ❑Bulk Solid- mpTiTanker ❑Tote(Paiiet(s) Drum(Si:e): PP Y ❑LDR Attachment ❑Bulk Solid•Dmp Tlr ❑Tote(s) ChemicalComposition Percent Minimum Maximum ❑Bulk Solid•Roll Off ❑Cubic YardBox(s) ❑Other(Size): Anticipated Volume: 30011-- Per n--fit`— F Quantity: Price: I Unit: F. SPECIAL HANDLING CONSIDERATIONS c + ❑PA RW SOG ❑Radioactive ❑No Land Filling ❑Etiologic/Medical Waste ❑DRMSIDRMO Waste ❑Incinerate Only ❑Fuming ❑CERCLA Waste ❑Recycle Only ❑Phenolics ❑Asbestos ❑Other: G. TRANSPORTER ARRANGEMENTS 19 CCl/GCC Provides Transportation 0 Other. O Customer Delivers to CCl/GCC Indicate if waste contains any of the following: 0 Customer Delivers to End Facility via CCl/GCC No •Re . or LessThan or ActuaPCB l H. OTHER HAZARDOUS CHARACTERISTICS Cyaanides o 250P M ❑RCRA REACTIVE Phenolics ❑ 50 PPM ❑WATER REACTIVE ❑ETIOLOGICAL ❑EXPLOSIVEISHOCK SENSITIVE ❑RADIOACTIVETER REAL ❑TSCA REG l�•NONE OF THE ABOVE Sulfides ❑ 500 PPM ❑OXIDIZING MAIL VOCs ❑ ❑ 50OPPM 113 SUBJECT TO SUBPART FF BENZENE REG ❑PYROPHORIC Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined in 40 CFR 268 Pad 2, through D043)? O Yes fJ�t•II0 Section I at concentrations exceeding the UTS treatment standards? O Yes JoNo If YES,please list the constilulrnts and concentrations in section C. If YES,please list the constituents and concentrations in section C. GENERATOR CERTIFICATION:I hereby certify that all information submitted In this and all other attached documents Is complete,contains We and accurate descriptions and Is representative of the waste matedat,and that all relevant Information regarding known or suspected hazards In the possession of the generator has been disclosed.If CCUGCC discovers,after having taken the delivery of the waste,that any waste does not conform to the Identification or descriptions contained In this MPS then CCUGCC shall provide notes to Generator and coordinate the return,if applicable,of the non conforming waste to the point of origin as set forth In the manifest or to such other locations designated In wriling by the Generator.Generator agrees to reimburse CCUGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCIIGCC during the recelpL handling,temporary storage and return of such non conforming waste to Its point of origin or to such other location designated by the Generator.I hereby authorize CCIIGCC to amend and/or correct any Information on the MPS with the full understanding that if any amendment or correction Is performed,I will be contacted as such to Issue any approval, Authorized Signature_e Title Date CCUGCC APPROVAL ales Code Tech Initials Date 7 Mana ement Initials Residual Waste? g Date Form Code: I ' .emaaaerae� Cycle Chem, Inc. General Chemical Material Profile Sheet C Gencode/Gen#: Stream(applicable) 217 South 1st St. 550 Industrial Dr. � C o r p o r a t i o n Elizabeth,NJ 07206 Lewisberry,PA 17339 Phone: (908)355-5800 Phone:(717)938-4700 133-138 Leland St.,Framingham, MA 01701 www.cyclechem.com Fax:(908)355-0562 Fax:(717)938-3301 Phone:(508)872-5000 Fax:(508)875-5271 process/ProductCode: .GENERATOR INFORMATION EPA ID# �r(a —,`_ n BILLING COMPANY Cv / GENERATOR NAME t^l Jt► t)f JC,�t+S i � � 1/1�I/ISr�A BILLING ADDRESS (X r MAILING ADDRESS n P BILLING CONTACT GENERATOR CONTACT BILLING PHONE# 45 0FAX GENERATOR PHONE# NAME OF WASTE: GENERATOR FAX 6 SITE ADDRESS trh a PROCESS GENERATING WASTE: CLLYiD B.PHYSICAL CHARACTERISTICS OF WASTE(AT 70"F) -- -----,Liquid/Solid/Sludge D.REGULATORY INFORMATION I Color/Odor/ Is it USEPA Haz waste? Q Yes Physical Description: r I%Liquid (;VNO %Suspended Solids T— USEPA Haz Codes: Wastewater: O Wastewater Non-wastewater %Sludge EPA Sub Categories: ` I Specific Gravity: %Solid � Is it STATE waste? Q Yes (p No O I Physical State: El Single Phase Solid [IDumpable? Yes No Gas/Aerosol � I STATE Haz Codes: ❑Bi-Layered L1 Liquid ❑Lab Pack !Pumpable? 0 Yes No Pourable? O Yes o DOT Hazardous Material?C�YeS NO ❑Powder ❑Multi-Layered [I Semi-Solid V I ��- Q❑Sludge -- -- - Proper Shipping Name: L\(tp ?An. ^2 Flash Point: O Flash Point<74 F O Flash Point 101-140 F Flash Point>200 F O Exact Flash Point: 7-�- O Flash Point 74.100 F 0 Flash Point 141.200 F Wo Flash Point I Hazard Class: r UN/NA#: P.G.: 0 Open cup O Closed cup Ignitable Solid? O Yes 0 No RQ: ERG#: pH: 0<2.0 O 2.01-5.0 &5.01-9.0 0 9.01-12.49 0>12.5 0 Exact pH E. SHIPPING INFORMATION C. CHEMICAL COMPOSITION Shipment Method: ATTACHMENTS: ❑MSDS attached ElSupplemental Analysis ❑Additonal information ❑LDR Attachment ❑Bulk Liquid•Tanker ❑ (s) ❑Drum(Size): [I Bulk Solid•Dmp Tlr ElTote Tote((s) Chemical Composition Percent Minimum Maximum ❑Bulk Solid•Roll ON ❑Cubic Yard Box(s)AOther(Size): Anticipated Volume: 20# Per Quantity: Price: /Unit: 12U-N IKUkVII2 F. SPECIAL HANDLING CONSIDERATIONS ❑Radioactive ❑ PA RW SQG ❑No Land Filling ❑Etiologic/Medical Waste ❑DRMS/DRMO Waste ❑Incinerate Only ❑Fuming ❑CERCLA Waste ❑Recycle Only ❑Phenolics ❑Asbestos ❑Other: G. TRANSPORTER ARRANGEMENTS F'CCIIGCC Provides Transportation 0 Other: 0 Customer Delivers to CCIIGCC Indicate if waste contains any of the following: O Customer Delivers to End Facility via CCl/GCC Non e. or LessThan or Actual H. OTHER HAZARDOUS CHARACTERISTICS PCBs ❑ PM Cyanides ❑ 250 250 PPM ❑RCRA REACTIVE ❑ETIOLOGICAL q EXPLOSIVEISHOCK SENSITIVE Phenolics 1 ❑ 50 PPM ❑WATER REACTIVE ❑TSCA REG RNONE OF THE ABOVE Sulfides 1 ❑ 5o0 PPM ❑RADIOACTIVE ❑OXIDIZING MAT'L vocs ❑ 500PPM 113 SUBJECT TO SUBPART FF BENZENE REG ❑PYROPHORIC Chlorides ❑ 1000 PPM 1.Is this waste characteristically hazardous for metals or organics(EPA Waste Codes D004 2.Does this waste contain underlying hazardous constituents as defined In 4D CFR 268 Part 2, through D043)? 0 Yes ONo Section I at concentrations exceeding the UTS treatment standards? 0 Yes No If YES,please list the constituents and concentrations in section C. If YES,please list the constituents and concentrations in section C. to GENERATOR CERTIFICATION:I hereby certify that all Information submitted In this and all other attached documents Is complete,contains true and accurate descriptions and is representative of the waste matedaL and that all relevant information regarding known or suspected hazards in the possession of the generator has been disclosed.If CCOGCC discovers,after having taken the delivery of the waste,that any waste does not conform to the Identification or descriptions contained in this MPS then CCIIGCC shall provide notice to Generator and coordinate the return,if applicable,of the non conforming waste to the point of origin as set forth in the manifest or to such other locations designated In writing by the Generator.Generator agrees to reimburse CCIIGCC for all handling,packaging,cleanup and transportation costs or charges,damage to equipment and costs associated with lost time Incurred by CCIIGCC during the receipt,handling,temporary storage and return of such non conforming waste to Its point of origin or to such other location designated by the Generator.I hereby authorize CCIIGCC to amend and/or correct any informal ign oy the MPS with the full understanding that it any amendment or correction Is performed,I will be contacted as such to issue any approval. Authorized Signature . /J Title Date F Cl/GCC Sales Code ResidualWastel PROVAL Tech Initials Date 7 Management Initials Date Form code: Ot Cycle Chem, Inc. General Chemical Corporatiod 217 South First St. 550 Industrial Drive 133-138 Leland Avenue -' Elaabetlr,NJ 07206 Lewiaberry,PA 17339 Framingham,MA 01702 �Si Phone:(908)355.5800 Phone:(717)938-4700 Phone:(508)827-5000 Fax(908)3554582 Fax:(717)93&3301 Fax(508)875-5271 LAND DISPOSAL RESTRICTION NOTIFICATION ARID CERTIFICATION FORM GeneratorNwne: �n(,y� BiO�,USTA.3L.E J /�iE�T�y �.z►��"SSy� a Generator EPA/D#: /���()� b 2- Manifest#: NJ g SZ-0 This land disposal restriction(LDR)notification must be submitted with the initial shipment of all new waste streams. Due to revised LDR notification requirements effective after August 23, 1998,previously approved waste streams will require re-notification on this form with the first shipment after that date. Subsequent notification is not required unless the waste stream changes. (1) WASTE STREAM INFORMATION Box A: Check this box if this LDR certification has been supplied with a previous shipment. Additional information and certification is not required on this form. Box B: Indicate if waste stream is a wastewater(WIN)or non-wastewater(NWW) (aqueous waste streams containing< 1%total organic carbon(TOC)and< 1%total suspended solids(TSS) are wastewaters. All other streams are non-wastewaters). Box C. List all EPA waste codes and subcategory reference letters(if applicable). Alternatively, attach and reference additional pages(e.g. profiles or lab pack slips)containing required information. A B C Previously shipped Line# LDR on file NWW I WIN EPA Waste Codes and subcategory reference letter if applicable) A WW i vo/ B Wk4) C D SubcategorjrReference Letters(EPA codes not listed here do not have subcategories) D001 A Ignitable characteristic wastes, except high TOC ignitable liquids subcategory D001 B High TOC > 10% ignitable liquid subcategory D003 A Reactive sulfide subcategory D003 B Reactive cyanide subcategory D003 C lWater reactive subcategory D003 D Other reactive subcategory D006 A Cadmium non-battery subcategory P006 B . Cadmium containing batteries subcategory D008 A Lead non-battery subcategory D008 B Lead acid batteries.subcategory D009 A High,mercury organic subcate o >260 PPM,Total Mercu D009 B Highmercuryino anic subcategory., >.260 PP.MZotalWercu D009 1, C Low mercury subcategory <260 P_Pnn Tota_I mdreu ' D009 ,, ' ,D_f Me(cury wastewater subcategory "` ^ir � K _ ter, �-- .�..4�:. sx� '•`r :. -- (1) CAS means Chemical Abstract Services. when the waste code and/or regulated constituents are described as a combination of a chemical its salts, and/or esters, the CAS number is given for the parent compound only. (2) Concentration standards for wastewate rs are expressed` in Ong/l and are based on analysis-of composite samples. (3) Except for Petals (EP or TCLP) and Cyanides (Total and Amendable) the nonwastewater treatment standards expressed as a concentration were established, in part, based on incineration in units operated in accordance with the technical requirements of 40 CFR part 264, subpart 0 or CFR part 265, subpart 0, or based on combustion in fuel substitution units operating in accordance with applicable technical requirements. A facility may comply with these treatment standards according to provisions to 40 CFR 268.40 (d). All concentration standards for nonwastewaters are based on analysis of grab samples. (4) Both cyanides (Total) and Cyanides (Amendable) for nonwastewaters are to be analyzed using method 9010 or 9012 found in "Test Methods for Evaluating Solid !Taste, Physical/Chemical Methods", EPA Publication SW-546, as incorporated by reference in 40 CFR 260.11, with sample size of 10 grams and a distillation time of one hour and 15 minutes. (5) Fluoride, selenium, sulfide, vanadium and zinc are not underlying hazardous constituents in characteristic wastes, according.to the definition in 268.2(i).. NOTE: HA means not applicable. Af. .. �..,- 'tip."`- -.. • .9 �.�!` =i, UMDBU MG HAZARDOUS CDRISTlTUEIZR'S UNIVERSAL TREAT,4fEMTSTANDARDS Regulated constituent Organic Constituents Common name CATS#1 WW NM m90 mgm A2213 3DSS643-1 0.042 14 2,4-Dini4 uene 121-14-2 OX 140 Wvexf2,4,5-TP 93-72-1 0.72 79 AcenaptMy{me 20696-8 a-% 3A 2,6-Dinitromluene 605-20-2 am 28 1,2,4,5-Tebachkuvbenmre 95494-3 OD55 14 Ace+aphthene 83-329 0D59 3.4 Di-n•octyl phthalabe 228.84-0 0D17 28 - TCDDs(AN Tebaddorodibeirm)NA ODOOD63 0401 Acemrx 6764-1 028 160 Di-rigaapylnihosanime 62164-7 0.40 14 TCDFs(AI Tebaidwmdi- } AcWmn&k 75-0S8 5.6 38 1,4-Dioxane 12391-1 12.0 170 benzohaans) NA OD00063 ODOI J AceOophenane 96-WZ 0,010 9.7 Dil;henyknire(diffiaR to 1,1,1,2-Tatraddaetlrare 63D-206 0D57 6D j 2-Acdylarrinafkrorene 53-W3 0059 14D distinguish from 1,1,2,2-Tetradtlorethane 79-34-5 0057 6.0 AcroMn 107-02-8 029 NA di mine) 122-39-4 092 13 Tetrxhlaa[thykTe 127-28.4 OD56 6D Aayamide 79-06-1 19 23 DiphenylnOrosamine(difficult 2,3,4,6-Tetrachlo ophennl S39D-2 OD30 7.4 Aaylorribie 10743-1 024 84 to dbNguish from Thwdiaab _ 59669-26-0 OD19 1.4 Aldtmrrb sultone 1646-884 0D56 028 dipharyWmine) W33-6 092 13 ThwphanaRmeOryl 23564-05-8 ODS6 1.4 ALAin 309-00-2 0421 0.0% 1,2-Dipheny1hydrazine 17266-7 0D87 NA -ropate 26419-73-8 0056 028 4-Am robphmyl 9267-1 OA3 NA D'aulfoGm 29B-044 OD17 62 Tduere MS-88-3 0.080 10 Mime 62-53-3 am 14 Dithiocarbansbes(total) NA OD28 28 Taxaphere 8MI-35-2 ODD95 2A Mtlraoeee I2O-12-7 OM59 3A Endosulfan I 959-98 8 01123 OD66 Triallaae - 23D3-17-5 OD42 1.4 Ararnibe 140-57-0 036 NA ErdoarNan 3321365-9 0029 0.13 Tribr� 75-25-2 Obi 15 alpha-BNC 319-846 000014 OD66 Endosu fan sulfate 1031-07-6 OD29 013 2,4,6-Tnbr-eptrinl 118-79 6 0.035 7.4 beta-BHC 319-85-7 OM014 OD66 Endrin 72-20-8 0.0028 0.13 1,2,4-Triddombbenzene 120-82-1 0D55 19 deha-BHC 319-86-8 0,023 0.066 Endrin aldehyde 7421934 0,02S 0.13 1,1,1-Tnd4orce0nmm 71-556 0054 6D gamma-BHC SB-89-9 00017 0.0% EFfC 759944 0D42 1.4 1,1,2-Trichlwetlrane 79-0o-5 0D54 6D Barban 101-279 0056 1A Ethyl be 141-786 0.34 33 Trtchlomethyknne 7"16 0A54 60 BeufrOvb 22781-23.3 0.056 IA Ethyl benzine IOD-41-4 0A57 10 Triddorortnrwlkrovmdlrane 7569 1 0,020 3D 8endicarb phewi 22961-@6 OD56 1.4 Ethyl cyanide/Propanenbile 107-12-0 024 360 2,4,S-Tn color phenol 95-954 OAS 7.4 Benonryl 1780435-2 0D56 1.4 Ethyl ether 60-29-7 0.12 160 2,4,b-T-libacphenol 88-06-2 0035 7.4 Benzene 7143-2 0.14 10 his(2-Ethythexyl)phthalate) 117-81-7 028 28 2,4,5-Triddor phewxyacetic Benz(a)anthracena S6-55-3 OD59 3.4 Ethyl methacrylate 9763-2 0.14 160 acid 93-76.5 0.72 79 Benzal dioide 98-87-3 0.055 60 Ethylene oxide 75-21-8 0.12 NA 1,2,3-Trichloropnopane 96-184 035 30 Benin(b)BnnranHnme 205-99-2 0.11 6.8 Famphur 52-85-7 0017 i5 1,1,2-Tnchlono-1,2,2-tri- (difiwuk to distinguish from benm(k)flo ranthe+ne) Ruorantherw 206-44-0 am$ 3A fluo-thane 75-13-1 0D57 30 Beim(k)flouranthene 207-059 0.11 61L Ruorene 86-73-7 0.059 3.4 Triethylanine 101448 0.OB3 1.5 (difficult to distinguish from be zo(b)flourantherm) Formetanate hydnxhWnde 23422-53-9 0D56 IA tris-(2,3-Dibrorropmpyl) Benzo(g,h,i)perylene 191-24.2 0D05S 18 Formpaanate 17702-57-7 01156 1.4 phosphate, 126-72-7 0.11 0.10 Benm(a)pyrane SD-32-8 0051 3A Heptachlor 76448 0.0012 OD66 Vemolabe 1929-77-7 0D42 IA Broxididnbromelhane 75-274 03S 15 HepacMor epoxide 1024-57-3 0D16 0D66 Vinyl chloride 75-014 - 027 6.0 b mide 7+83-9 0.11 15 Hmachlorobenzene 118.74-1 ODSS 10 Xyleres-muxed isomers(sum 4-Bromophenyi phenyl ether 101-55-3 0.055 15 Hesachbrbu adene 8768-3 0455 5.6 of o-,m-and p-xylem n-Butyl alcohol 71-36-3 5.6 2.6 Haachlorocyctopertadierim 77474 0057 2A concentrations) 133D-20-7 032 30 "late 200841-5 0042 1.4 - F.CDDs(ail Hexachbrodib-m Intirgaoc Cbm ilia mts W bemyl phtlulate 8568-7 0,017 28 p-doxins) NA ODOOD63 0001 Antinomy, _ 7440-36-0 i9. 1.15 nw TCLP 2-sec-Suty"Adsuhaphewl HxCDFs(all Hesafibrodbmm- Arsenic 7440-38-2 IA 50 mg/l TCLP /Dmoseb 88-85-7 0D66 25 furars) NA ODDOD63 0001 Barium 744D-39-3 12 21 ngp TCLP Cadreryl 6325-2 a," 0.14 Herachbroe0wtre 67-72-1 0.055 30 Beryllium 744041-7 0.82 122 mg/i TCLP Carbenzadkn IMOS-21-7 0056 1A Heaxhloropropylene IM-71-7 0035 30 Cadmium 7440-439 0.69 0.11 m9A TCLP Qrbofuran 156366-2 0D06 0.14 indew(1,2,3-c,d)pyrme 193-39-5 0=55 3.4 Chroriun(Total) 7440.47-3 2.77 0.60 mg/1 TCLP Cadwfuran phenol 1563-38.8 ODS6 1.4 rodomethane 74.86.4 0.19 65 Cyanid(Total)4 57-12-5 12 590 Carbon disulfide 75-15-0 38 49 mg/l TCLP Lsobutyl ab*d 78-83-1 5.6 170 Cyanides(Amenable) 57-12-5 026 30 Carbon Tetrachloride 56.23-5 0D57 6.0 isodrin 465-736 0021 0166 Fluorides 16984.48-8 35 NA Carbosulfan 5S285-14-8 OD28 IA 7mLin 119-38-0 0056 1A lead 7439-92-1 0.69 0.75 mg/1 TCLP Chlorodane(alpha and lsosafrde 120-SB-1 0.081 2.6 Mercury-NV WV from Retort 7439976 NA 020 rTVA TCLP gamma isomer) 57-749 0.0033 026 Kepone 143.50-0 0.0011 013 Mersey,-All Others 7439-976 OAS 0D25/nVA TCLP p-abroandine 106-47-6 0,46 16 Methylaaylmitrile 126-98-7 024 84 Nicw 7440-02-G 398 11 mg/l TCLP Chlorobmzene 108-90-7 0057 60 Methanol 67-56-1 5.6 0.75 nW TCLP Selenium' 778249-2 OZ2 5.7 ngjl TCLP Chbrobem7ate 510-156 0.10 NA Methapyriene 91-8D-5 0.061 15 Sitvw 7440-24 0.43 0.14 mg/l TCLP 2-Chbro-1,3 bumdene 12699-8 0057 028 Methiocarb 203265-7 aim 1.4 Sulfides 18496-25-8 14 NA Chim bloc ortcihanw 124-413-1 OD57 15 Metlwmyi 167S2-77-5 OD28 1.14 Thallium 7440.23-0 1.4 020m g44 TCLP Chioroet ane 75-00-3 0.27 6D Medwychlor 7243-5 025 0.18 Vanadium s 7440-62-2 43 lb mgfi TCLP Bis(Z-04 odd,my)metlnane 11191-1 0.036 72 3-MethyWicilarthrene 5649-5 0.0055 is Zinc 7440-66-6 26i 43 mgA TCLP Ns(2-ChW*ethyi)ether 111 44 4 OD33 611 4,4-Methylene bis(2drloranilne)301-144 050 30 Chlaofam 6766-3 0D46 fill Methylene chloride 75-09-2 0D89 3D Bis(2-Chfaoisopropyl)ether N638-329 0,055 72 Methyl ethyl ketone 78-93-3 028 36 P-cbw-m-ezesol 59-SD-7 0D18 14 Methyl aobutyl ketone 108-10-1 0.14 33 2Chbroetheyl vinyl ether 110-75-8 0D62 NA Methyl methacrylate 80-626 0.14 16D Chloro ethane)Methyl chloride 74-87-3 0.19 30 Methyl rme0unsulforate W27-3 0.018 NA 2-Chloronaphthal ne 91-58-7 OD55 5.6 Methyl paadion 298-00-0 0D14 4b 2-dddoaphenol 95-57-8 0.00 5.7 Mebolcafi 112941-5 0056 1A 3-Chbnpropylere 107-05-1 OD36 30 Mexacarbate 315-184 0D56 1.4 Chrysere 213-019 0D59 3A Mdirute 221267-1 0.042 1A o-crrsd - 954E-7 0.11 5.6 Naphthalene 91-20.3 0.059 5.6 rrroesol(dif6nC to 2-Napthytarine 91-99-8 am NA distinguish from p aasol) IM-39-4 0.77 5.6 O-NLtroaniine 88-744 027 14 p-asal(dH6nit to p-retroaniim 1OD-016 0.028 28 distinguish(rum mcresoi) 306445 0.77 Sb Nitrobenzene 989S-3 0.068 14 mCumneryl methylearbonabe 64-0D-6 0.056 1.4 5-Nitrob-boWidne 99-55-8 03L 28 Cyrdohaanone 10894-1 036 0.75 mg/l TCLP o-Nitrophenol 88-75-5 OD28 13 op-DDD S3-19-0 0D23 0087 pritropftenol IOD-02-7 0.12 29 p,p'-DDD 72-54-8 0.023 0D87 N-Ni wAdiethylamme 55-18-5 0.40 2B o,p-DDE 3424-826 OD31 0.087 N-Nitrosodirrethyli3mim 62-759 0.40 23 p,pr-DDE 72-559 OD31 0D87 N-Nitrosodrmbutylamne 924-16-3 0.40 17 ' o,p'-DDT 789.026 0=39 0D87 N-Nitro ylethylamine 10595456 0.40 23 p,p`-DUT 50-29.3 OD039 OD87 N-Nitrwortnrphdne 59-89-2 0.40 23 Dibenz(a,h)ariftwe a 53-703 0055 882 N-Nihoeapipar dine 1OD-754 0013 35 Dibrenz(a,e)pyrare 192654 0461 NA N-Niboeopymilidne 930-55-2 0D13 35 1,2-Dn'bro a-3drbropropane W12-8 0.11 15 onnrl 23135-22-0 0056 029 1,2-Dibrorrwethare4@hylene Parathion W38-2 0014 4.6 dibrorride 106-934 Ome 15 Total PCBs(sun of all PCB Dibronorellnane 74-9S-3 0.11 is Lsorres,or all Amdons) 1336-36-3 0.10 10 m-ddiorobenzere 541-73-1 OA36 6.0 Pebulabe 111+71-2 OD42 IA D-Dichbrbenzene 95-50-1 aim 6.0 Pentachloroberizerie 60893-5 0.055 10 p-Diddorobenzece 106-46-7 0D90 60 PeCDDs(All-PenticNeodkertm Dichbrodifkwmmeftme, 75-71-8 023 72 pdioxinss) NA ODD0063 0D01 1,1-OkhlooeNnarx 7543-3 0D69 6D PeCOFs(Ali RsrGdiloo- 1,2-Didrbtoetlure 107-06-2 021 6.0 hetmfiaans) NA 0.000035 0.001 1,1-Dichloroetlryleme 75.354 OA25 6.0 Retthddoroetlune 76-01-7 OD55 6,0 trams-1,2-0i1lorodhylme 1566D-5 ODS4 3D Henmddoranitrobenzene 8268.8 0D55 48 Z4-Dwhiorophend 12083-2 0.0" 14 Penaidrloropheol 87-WS 0.089 7.4 2A-DkhWmphe of 87.65-0 Dim 14 Phwwwbn 6244.2 ODBI. 16 Mienandrene 85-01-8 0D59 SA addj2A-D 94-75-7 0.72 10 Nrswl 30845-2 OD39 62 1,2-Diddwq-pane 78.67-5 025 i8 o-phdryleudemine 95-54.5 Dim 5.6 cis-12-fthimpropy1e1e 10061-01-5 CA36 is Karate 296-02-2 0D21 - 4b bars-I,D-DWftr 10061-M6 OD36 i8 Phthaib add 100-21-0 0.055 28 Die" 613-57-1 0,017 0.13 Phtha8c anhydride 8549.9 OlKS 28 Dietlrylee g",dcabirtabe SM 26.1 OD56 L4 Physa ft. a 57476 ODS6 L4 Oldhyl phtlulabe 911 62 020 28 Nrysoftigrine sakviate 57.647 OAS5 L4 -0"ntblry�vwaaoberzane WU-7 0.13 NA Rolm b 2631-37-0 OD56 L4 2401me yl pha d 105679 OD36 14 hazaride 23950-SM OA93 15 Dbre"plMWabe 131-11-3 OA47 28 Popham 122429 OA56 L4 n, -,n 64464.4 DAN 1.4 hop- 11+26.1 DAN 1.4 Di-zrbtAyl phthalate -84-74-2 0.057 28 Rsadfioaeb 52886.111" Dim 14 1.4 Dk*mbeaene IO03S4 0.32 23 Pyrene 1294" 0.067 8.2 4.r'4Dltdbootrosol S34-S2-I 0.28 160 Pyrkww 110860 0.014 36 2,4WzYCOpherol Sl-28i 0.12 160. sanole 94.59.7 0.081 22 (2) SPENT SOLVENT WASTE CONSTITUENTS - Circle applicable waste code(s)and constituent(s)for each manifest line item containing EPA spent solvent waste codes FW I-F005. A B C D F001 ABCD F002 ABCD F003 ABCD F004 ABCD F005 k ABCD -acetone ABCD -ethyl ether ABCD -benzene A B C D -methanol ABCD -n-butyl alcohol A 8 C D -methylene chloride ABCD 4so-butyl alcohol ABCD -methyl ethyl ketone ABCD -carbon disulfide A-B C D -methyl isobutyl ketone ABCD -carbon tetrachloride ABCD -nitrobenzene ABCD -chlorobenzene A B C D -pyridine ABCD -m-cresol ABCD -tatrachloroethylene ABCD -o-cresol . A B C D -toluene ABCD -p•cresol ABCD -111,1-trichloroethane A B C D 7cresylic acid A B C D -1,1,2-trichloroethane A B C D 7cyclohexanone ABCD -trichloroethylene ABCD -o-dichlorobenzene ABCD -trichloromonofluoromethane A B C D—______-ethyl acetate ABCD 1,1,2-trichloro-1,2,2-trifluoroethane ABCD -ethyl benzene A B C D -xylenes c (3) UNDERLYING HAZARDOUS CONSTITUENTS r For characteristically hazardous waste streams(EPA codes D001-D043), please list all underlying hazardous constituents as defined in 40 CFR 268(2)(i)that are present at concentrations exceeding the universal treatment standards listed in 40 CFR 268.48(F001-F005 constituents identified in section(2)and specific constituents for EPA U-, P-,and D004-DO43 codes listed in section(1)do not need to be listed in this section). A. None Present A. None Present A. None Present A. None Present (4) HOW MUST THESE WASTE STREAMS BE MANAGED? For each manifest line item,circle applicable treaiment/requirement. For contaminated soil,circle applicable choice as indicated. A B.C D_' This waste is non-hazardous per 40 CFR 261,and is not restricted from land disposal under 40 CFR subpart D. D"This is an EPA hazardous waste that is not a contaminated soil or hazardous debris. Waste must be treated to the appropriate treatment standard set forth in 40 CFR subpart D prior to land disposal. ABCD_This is a hazardous debris(>60mm/2.36 inch)and is subject to the altemative treatment standards of 40 CFR 268.45. ABCD_This is a hazardous waste contaminated soil. This contaminated soil does/does not(circle�)contain listed hazardous wastes and does/does not(circle or*) exhibit a characteristic of hazardous waste and is subject to/complies with(circle—the soil treatment standards as provided by 268.49(c)or the universal treatment standards. A B C D_This is an EPA hazardous waste that meets all applicable treatment standards set forth in 40 CFR 268 subpart D, and can be landfilled without further treatment. I certify under penalty of law that I have personally examined and am familiar with the waste through analysis and testing or thorough knowledge of the waste to support this certification that the waste complies with the treatment standards specified in 40 CFR Part 268 Subpart D and all applicable prohibitions set forth in 40 CFR 268.32 or RCRA section 3004(d). I believe that the information I submitted is true,accurate and complete. 1 am aware that there are significant penalties for submitting a false certification,including the possibility of a fine and imprisonment. (5)CERTIFICATION I certify that all information on this and all associated documents Is complete and accurate to the best of my knowledge. 1 Signature: - Title: Printed Name: Date: IF , l (�i► C.��-C-.'' air ai J J 'ir. r.J �Y/ Y.r.� I l� '. J � 1 1 EPA ID NUMBERS ""` 11 _T J NOTICE TO OUR CUSTOMERS J FROiM GENERAL CHEMICAL CORP. AND CLEAN VENTURE, INC. We have prepared this regulatory information for your benefit, in order to help you stay- in compliance with complel'hazarclous waste regulations. The EPA identification number is a 12-character number assigned to a specific location where hazardous waste is generated. It is used by the EP__-11 ency or State Ag (NIA DEP) to track hazardous waste activity originating at that site. A regular permanent ID number is required for sites that will_have ongoing waste generation activity. However, since some waste producing activities are temporary, and it takes time to apply for and receive a permanent ID number, most states have provision for issuance of temporary ID numbers. Temporary or "provisional" ID numbers are generally limited to one time or short- term use. In all New England states other than M_=�, you must contact the enVironmcrtal agency in order to obtain a provisional number. However, =CIA DEP allows generators to self-assign an ID using their phone number. The attached sheet describes how this may be clone and the limitations on its use (30-clay limit on "NIP" numbers). To obtain a provisional ID number otlt.,i,� � le NIA, y-ou should contact the state agenc-,. at the phone number shown below: CT— (860) 424-3566 — a �^ CIE — (207) 287-7827 (Ext. 2651)-) t NH — (603) 271-2901 or 2902 —ftCIO Ckf,1Slk 1"-1 ; �0 il�a��s Q OCS. SN�Z OYN,VS RI — (401) 222-1360 (Ext. 7132) VT — (802) 241-3119 If you need a permanent EPA ID number, you can obtain the 1'IA DEP application form from your customer service representative (it will soon be available on DEP's web site www.state.ma.us/den): (For other states, call the number listed above). If you have any questions about this information, please do not hesitate to contact our compliance department. r --o CS �S Z�z'it /o3 emorandum } To: Ed Price Gary Hoadley Jim Dilts Gayle Garlick From: Roy Swartz Date: 4/4/02 Re: Generator EPA ID Numbers I've been noticing a lot of"temporary" ID numbers on manifests. It should be common knowledge that an ID number is tied to a specific site and that temporary numbers are appropriate only for one-time or short-term use. However, the states in our region have different approaches to compliance. Therefore, I wrote to the environmental agencies of all six New England States for their current guidance on i ces. The state specific fferen this subject. Not surprisingly, there are big d �, summary provided below should help us all better serve our customers by providing them with the information they need to avoid enforcement action. Massachusetts Two items are attached for use by MA generators: • Instructions for self-assigned Generator Identification Numbers —this sheet includes all the information needed to get a one-time or short-term (30-day's) ID number. In MA, the generator may assign a temporary ID number without having to contact DEP. • Application for US EPA Identification Number—This should be used by any generator who will be generating waste for more than 30 days and does not have a permanent ID number. Connecticut In CT, the spill reporting requirements usually result in a DEP representative being present at the cleanup. ID numbers in these instances are to be obtained from the on-site representative. For other single use, short-term or permanent ID number needs, the generator should call CT DEP at (860) 424-3566 and ask for inga Rubecka. New Hampshire NH also typically dispatches.a DES representative to spill sites, and that individual will assign a single-use ID number. For other situations, the generator should call (603) 271-2901 or 2902 (Monday— Friday, 8:00 a.m. -4:00 p.m.) or (800) 346- 4900 (off-hours). f If this call is made by someone other than:the generator, DES will call generator to verify all information. ID number questions should be referred to Ray Gordon at (603) 271-6350. Rhode Island In RI, a short-term ID number can be obtained by calling Teresa Ryan at (401) 222- >1360 (Ext. 7132). This ID number will be good for 90.days and a permanent ID application should be requested if appropriate. Maine Maine has a unique definition for"Small Quantity Generator (SQG)", with limitations of 100 kg. /month and one 55-gallon drum of accumulation. This may be useful in small spill situations, as any SQG cen use a statewide ID number of MEX020000000. Otherwise, "provisional" ID numbers are assigned by phone during normal working hours. Call Ed Vigneault at ME DEP (207) 287-7827 (Ext. 2651). A provisional ID number may be used only once, so repeat generators must request an application for permanent ID if appropriate. Vermont VT requires submittal (via fax) of a special form for "provisional" EPA 1D numbers (See attached). They will call the contact person identified on the form and provide the assigned number. Contacts at VT DEC are Linda Woodward or Sheri-Kasten at (802) 241-3119. 0��L oy �al.�� !a 3"7 •r yloL GUIDE TO DETERMINING STATUS AND REGULATORY REQUIREMENTS This matrix does not reflect ACUTELY Hazardous waste waste Oil management Transport Management Requirements Regulatory St' Hazardous Waste Management g Requirements Accumulation Limits Accumulation Limits q . Volume In lank, Volume In Lk"I Uat Luy SO A[nmolallon rm[gtney hnenntl IlatanloVa lVatlt Time Volume In ranks Volume In llm[ Conuinen by IOar+l hd containers h61 Manlleq Lan+pan Area Aardardt Pr[parallon Tuinin�t r Watle OH IDaytl hD Hat Watt[ `•' Conies/envy . andlor Plank L Waste Oil Eknnbl Rpl rFF ;• LQG LQG 90 NO LIMIT NO LIMIT . 90 NO LIMIT NO LIMIT YES YES YES YESYES LQGSQG 90 NO LIMIT NO LIMIT 180 0000' 2000 YES YES LQG _ VSQG 90 NO LIMIT NO LIMIT NO LIMIT 600 600 YES' YES(wo1 YES LQG NONE 90 NO LIMIT NO LIMIT N/A N/A N/A YES YES YES A YES YES T SQG LQG 100 6000-' 2000 90 NO LIMIT NO LIMIT YES 1 SQG 1n0 YES YES O SQG 0000 2000 180 0000 2000 YES N SQG VSQG 180 6000• 2000 . NO LIMIT 600 G00 YES' YES(wo1 YES YES YES YES O SQG NONE 180 6000- 2000 N/A T N/A N/A YES E VSQG LQG NO LIMIT 600 600 90 NO LIMIT NO LIMIT YES- YES(tnv) YES YES P YES YES A NONE LQG N/A N/A N/A 90 �10 LIMIT NO LIMIT YES T VSQG SQG NO LIMIT 600 600 180 6000" 2000 YES' YES(ttwl YES YES O VSQG VSQG NO LIMIT 600 600 NO LIMIT 600 G00 YES YES YES VSQG NONE NO LIMIT G00 Ann N/A N/A N/A YES' YES YES E, YES YES p, NONE SQG, N/A N/A N/A 180 6000 2000 YES " 00 YES NONE VSQG N/A N/A N/A NO LIMIT G00 G YES YES _ • A manifest must be used for the VSQG category unless self transported. �• - d containers, the total accumulation cannot exc When accumulating in both tanks an eed G,000 kilograms and the container accumulation cannot exceed 2,000 kilograms. • Kilograms/Month (Generation) Conversions: Kilograms. 220unds Gallons (varies by substance Def'initioris: Regulatory Status 0 LQG 1000 OR MORE • r 600 1320 150- 1 G5 SQG 1 b0-999 ;.. VSQG LESS THAN 100 1000 2200 250-2G5 ' 2000 4400 500-550 REV IrY3cv96 ci • ' ';;'. 0000 13,230 1500- 1G50 . RAB/CENTRAL I f a c t s h e e i INSTRUCTIONS for SELF-ASSIGNED M a s s a c h u s e t t s GENERATOR IDENTIFICATION NUMBERS D e p a r t m e n t uf ENV IRONMENTAIL P R O T E C T I O N To whom does this apply? * New generators who manifest their hazardous waste and need to notify of their continuous hazardous waste activity(VSQG's and/or SQG's of waste oil) *Generators (LQG's and SQG's)who are waiting for a permanent EPA ID (provisional) It * Generators of short term (30 days) or one time only hazardous waste clean-out activities *Generators/responsible parties of hazardous waste produced from spill clean-up activities if no permanent ID at the site To whom does this not apply? Any generator which, prior to October 1, 1992, was assigned a permanent site-specific Massachusetts Department of EPA or DEP number. Environmental Protection How to self-assign your number: (example - MV413289456) One winter Street Boston,MA 02108-4746 Category Prefix + 10 digit Register? Telephone Number - Commonwealth of New generator(VSQG and/or SQG of waste oil) MV Yes Massachusetts New generator awaiting EPA ID (SQG or LQG) MP No Short term generator MP No Spill clean-up, one time cleanout MP No Jane Swift,Governor All MP numbers are temporary. All MV numbers are long term and do not change as Executive Office of long as the type and level of hazardous waste activity remains the same at this site. (If Environmental Affairs your area code has changed, you do not need to change your number.) If you move, you need to self-assign a new number and re-register. Bob Durand;Secretary Definitions: Department of Environmental Protection *VSQG (Very Small Quantity Generator)-generates less than 100 kilograms (27 En gallons) in a month's time (and no acutely hazardous waste) Lauren vi Liss,Commissioner * SQG (Small Quantity Generator)- generates less than 1,000 kilograms (270 gallons) Produced by the and more than 100 kilograms in a month's time Bureau of Waste Prevention Business Compliance Division ' LQG (Large Quantity Generator)-generates more than 1,000 kilograms a month April 2001.Printed on recycled paper. This Information is available In alternate format by calling our ADA Coordinator at (617)574-6872. Self-assigned ID•Page 1 of 1 A Application for U. . EPA * For official use only: .............. .......... Identification Number EPA IDNttmber Notification of Hazardous Waste Activity in Massachusetts Date Issued Instructions Return to: MA DEP Please print. For assistance in completing this form,or to All hazardous waste transporters and receiving facilities must Hazardous Waste report any changes in your hazardous waste activity,call the also obtain this federal identification number. Management Hazardous Waste Compliance Assistance line at Program, (617)292-5898. You should allow up to three months for the assignment of this One Winter Street number which will be mailed to you by the U.S.Environmental 8th floor, Every generator of hazardous waste who is generating more Protection Agency(EPA). While waiting for the official number, Boston,MA than 27 gallons of hazardous waste per month and/or more you may self-assign a temporary number by using the prefix MP 02108 than 270 gallons of waste oil per month must have a unique, and your 10 digit telephone number(including area code). Attn.: site-specific federal identification number. Notifications Note: The Applicant Information Massachusetts Department of Environmental Protection is 1. Notifying company: 4. Contact person to be telephoned regarding information on authorized by the' this form: U.S.EPA to ......................................-...........__........................................................................................._............................................. .......... administer the Name of Notifying Company notification Name _.............................._.........__......_............._.............................._.............................._...........-................................. process(310 Site of Hazardous Waste Activity CMR 30.303(2)). Title .........................................................................................................................._.._.................................._........ .......... City/Town _..................._----------._-___.__.-.--......_.___.._..............._............ ___..____.____..... Address State Zip Code Telephone Number including area code and extension' 2. Mailing address: 5. Ownership-Enter the name and address of the person or ...................................................:.................................................................................................................. corporate entity which is the legal owner of the business, P.O.Box or Street and the same for the property. Check type of ownership- ......................................................._...._................_...:.........................................._.............._.._._...................... City/Town Name of Legal Owner of Business ......................................._...._........_.................................._................................................................................_....................... Statelip Code ........................................._..........._................._.._._—..._.........._._........... Mailing Address 3. Standard Industrial Classifications)-(consult your .... ........................._..........................................................._......._..............................................-_.........._ industry fact sheet): Cay(rown State Zip Code ...................................................................................................................................................._.......................................... ❑ Federal ❑ State _ County ❑Municipal a. Four-digit SIC ❑ Indian ❑ Private Other ..........................................................................................................._. Description ......................................._...._......._........._._......._..-.--.-.-...---------- Name of Legal Owner of Property b. Four-digit SIC Code Mailing Address Description -........................................._........_...................................._......................._-..........._........._.............-............_.........._........-. City/Town State zip code ❑ Federal ❑ State :- County ❑Municipal ❑ Indian ❑ Private ❑ Other Rev.12/98 Page 1 of 3 Application for U.S. EPA Identification Number.� ber Notification of Hazardous Waste Activity in Massachusetts Description of Hazardous Wastes To complete this section you may need to have your waste analyzed. Consult your industry fact sheet or the Massachu .................................._...._...._...._................................. ........_.........._.....-._.-....................................._.............._._..... ...... setts Hazardous Waste Regulations(310 CMR 30.000) z. obtained from the State Book Store,State House in Boston at ................................................................................. ......................................................_............... .......-................... (617) 727-2834 or Springfield at(413)784-1376. 3. 4. ........................... ........................................................................................... Enter the four-digit code for each of your hazardous wastes. 5. 6. Attach additional sheets if necessary. Transporters are not required to complete this item except for waste they generate. 7. 8. ' Type of Hazardous Waste Activity Generator Categories-Check only where applicable: Waste Fuel and Used Oil Activity(310 CMR 213-268) -Check only where applicable: 1. Maximum monthly rates of hazardous waste generation (see 310 CMR 30.000): 1. ❑ Burn hazardous waste fuel(Federal Boiler&Industrial Furnace Requirements apply.) a. Ci Large Quantity(2,200lbs/270 or more gallons per month or more than 1 kg of acutely hazardous Type of combustion device: waste) ❑ utility boiler industrial boiler ❑ industrial furnace b. I:_i Small Quantity(less than 2,200lbs/270 gallons and more than 27 gallons per month or less than 1 kg 2. Market hazardous waste fuel: Note for section D: of acutely hazardous waste) ❑ generator marketing to burner ❑ other marketer * If your waste c. I=] *Very Small Quantity(less than 100kg/27 gallons 3. ❑ Burn used oil fuel(Recycling Permit required): generation is in per month and no acutely hazardous waste) this category only, Type of used oil fuel: you need a DEP 2. Maximum monthly rates of waste oil generation: ❑ specification(Table 310 CMR 30.216) Hazardous Waste ❑ off-specification Generator L_i Large Quantity(270 gallons or more per month) Registration Type of combustion device: Form. ❑ Small Quantity(less than 270 and more than 27 ❑ space heater utility boiler Forms may be gallons per month) I! industrial boiler industrial furnace obtained by calling the ❑ *Very Small Quantity(less than 100kg/27 gallons 4. Ci Market used oil fuel Massachusetts per month and no acutely hazardous waste) Department of Type of used oil fuel: Environmental 0 specification off-specification Protection. From the 617 area License or Permit Activity-Complete this section if a permit, or outside MA dial license,or application for license is on file with the Massachu- (617)338-2255 setts DEP. Check only where applicable: and choose option 2. ❑ Transporter of hazardous waste From area codes ❑ Transporter of waste oil only 413,508,781,or ❑ Transporter of precious metal waste only 978 dial ❑ Recycler(commercial/level III) 1-800-462-0444 ❑ Treatment,storage disposal facility and choose option 2. Rev.12/98 Page 2 of 3 A Application for U.S. EPA ' irk# Identification Number Notification of Hazardous Waste Activity in Massachusetts Certification "I certify under penalty of law that I have personally examinedand am familiar with the information submitted in .............................. ._._...._......._...___..............................__..........._..............._................._........_......._............._........_...._........ this document and all attached documents and that based on Signature(legal owner or chief operating officer at the site) my inquiry of those individuals immediately responsible for obtaining the information,I believe that the submitted information is true,accurate,and complete. I am aware that Print Name there are penalties for submitting false information,including the possibility of fine and imprisonment. .................................._..........._.........._.........._.._...._...._..........................._............_...__.........._.................._....._........._...._.:.. "In addition, I understand that any material supplied with official Title this application will not be considered confidential unless I specifically request that such material be kept confidential and the Department has made a determination of confidentiality in .............................__...._.................... accordance with 310 CMR 3.00 regulations governing.access Date Signed to,and confidentiality of,Department records and files under the Hazardous Waste Management Act." Return to: MA DEP Hazardous Waste Management Program, One Winter Street 8th floor, Boston,MA 02108 Attn.:Notifications Rev.12/98 Page 3 of 3 s/AF Cycle Chem, Inc. General Chemical Corporation 217 South First St. 550 Industrial Drive 133-138 Leland Avenue Elizabeth,NJ 07206 Lewisbe",PA 17339 Framingham,MA 01702 Phone:(908)355-5800 Phone:(717)938-4700 Phone:(508)827-5000 %�(J(� �y�y�.V\-O- Fare(908)355-05W Fax:(717)938-3301 Fax.(508)875-5271 LAND DISPOSAL RESTRICTION NOTIFICATION AND CERTIFICATION FORM Generator Name: 0- 6,QnAM4QL-l'- - NeAXT b,YVXa1-Ut" s � 71C/IZ Generator EPA/D#: l A C�� �2q6�r Manifest#: 2� This land disposal restriction.(LDR)notification must be submitted with the initial shipment of all new waste streams. Due to revised LDR notification requirements effective after August 23, 1998,previously approved waste streams will require re-notification on this form with the first shipment after that date. Subsequent notification is not required unless the waste stream changes. (1) WASTE STREAM INFORMATION. Box A: Check this box if this LDR certification has been supplied with a previous shipment. Additional information and certification is not required on this form. Box B: Indicate if waste stream is a wastewater(K*or non-wastewater(Ni M (aqueous waste streams containing< 1% total organic carbon(TOC)and< 1%total suspended solids(TSS) are wastewaters. All other streams are non-wastewaters). Box C.- List all EPA waste codes and subcategory reference letters(if applicable). Altematively, attach and reference additional pages(e.g. profiles or lab pack slips)containing required information. _ A B C Previously shipped Line# LDR on file NWW/WINEPA Waste Codes and subcategory reference letter if applicable) A V�v� e - c D .x Subcategory Reference Letters(EPA codes not listed here do not have subcategories) D001 A Ignitable characteristic wastes, except high TOC ignitable liquids subcategory D001 B High TOC > 10% ignitable liquid subcategory D003 A Reactive sulfide subcategory D003 B Reactive cyanide subcategory D003 C Water reactive subcategory D003 D Other reactive subcategory D006 A Cadmium non-battery subcategory1 4006 B Cadmium containing batteries subcategory D008 A Lead non-battery subcategory D008 ' ' B Lead acid batteries,subcategory D009 A High-me-rcu anic subcategory >260 PPM,Total Mercury). ; D009 B High mercury inorganic subcategory p26Q PPMTota1 Mercury) D009 kC Low mercurysubcate o <260 P_W7 TetiiLM rdu , -- ,., D009D% {I Ve.•rtu wastewater subcategoryv � t �l (1) CAS means Chemical Abstract Services. when the P ) 1 waste code and/or regulated constituents are described as a combination of a chemical its salts, and/or esters, the CAS number is given for the parent compound,on'IV. (2) Concentration standards for wastewaters are expressed in mg/I and'are based on analysis of composite samples. (3) Except for.Metals (Eli or TCLP) and Cyanides (Total and Amendable) the nonwastewater treatment standards expressed as a concentration were established, in part, based on incineration in units operated in accordance with the technical requirements of 40 CFR past 264, subpart 0 or CFR part 265, subpart 0, or_ a.sed on combustion in fuel substitution units operating in accordance with applicable technical requirements. A facility may cbmply with these treatment standards according to provisions to 40 CFR 268.40 (d). All concentration standards for nonwastewaters are based on analysis of grab samples. (4) " Both cyanides-(Total)-and Cyanides (Amendable) for nonwastewaters are to be analyzed using method 9010 or 9012 found in `"Test Methods for Evaluating Solid Waste, Physical/ChemicalMethods", EPA Publication 5w-846, as incorporated by reference in '40 CFR 260.11, with sample size of 10 grams and a distillation time of one hour and 15 minutes. (5) Fluoride, selenium, sulfide, vanadium and zinc are not underlying hazardous constituents in characteristic wastes, according to the definition in 268.2(i). (COTE: MA-mean not applicable. i s UNDERLYIAIG HAZ4RWI/S COMSIlTUEAlTS UNIVERSAL TRUMENTSTARIDARDS Regulated constituent �. ,rt .f► Organic Constituents Common name CAS#1 WW NM ml/hz mg/kg' AU13 3055843-1 OD42 1.4 2,4-DinitroToluene 121-142 0.32 140 Silrex/2,4,54P 93-72-1 0.72 79 Acenaphthylem 2DB-96-8 059 3A 2,&Dfnitrotoltrene _ 606-2D-2 O55 ZB 1,2,4,5-T�b m robenie 95.94-3 0055 14 Acenaphtlicro 83-329 0D59 3.4 Dftir-oL*phthalate "'• 2284" 0017 28 - TCDDs(Ali Tebaddorodibenzb)NA OADOD63 0=1 Acetone 6764-1 028 160 Diryrvpylnitraamine 621-6I-7 0.40 14 TCDFs(AI Tebadorodi- _ Aortonitrile, 75-05-8 5.6 38 1,4Dioxane 12391-1 120 170 bmmhraru) NA ODOOae ODDS Acetophmare 96-86-2 O1010 9.7 Diphenylar ine(diffivc to .. 1,1,1,2-Tezrachkwetha a 630-206 OD57 610 2-Aaelylarnninofkwrere 5396-3 OA59 140 dstirgush frmn 1,1,2,2-Tebarhk>mthame 79-34-5 OD57 610 ACroWn 107.02.8 029 NA diphenylrilzosamne) M-394 092 13 - Tetradtloraethylere 127-184 0.0% 6D Aayaride 79.06-1 19 23 Diphenyhttraenine(diffeutt 2,3,4A-TebacMorcphmel - SS9D-2 OD30 7.4 Aayloreb'ie 107-13-1 024 84 to distinguish from- i Thlodiarb 59669-26-0 0019 L4 Ald'earb sdforre 1646-884 O.056 028 dipharylanine) - 86-30-6 092 13 Thiopharebt ethyl .. 23564-05-8 0056 L4 Aldrin 3D9-00-2 0021 OD66 IA-Diphmy1hydtazine M-W7 OD87 NA Tirpate " 26419-73-8 OD56 , 028 4Anvwbphenyl 9267-1 0.13 NA Doulfoton - 298-044 OD17 61 Toluene 108-W-3 am. 10 Aniline 62.53-3 0.81 14 Dnhiccarbanetes(fatal) NA O.028 28 Taxaphene 8001-35-2 0.OD95 2.6 Ant racene 120.12-7 OD59 3.4 Erdosulfan I r 959-9" O.023 OD66 Triallate 2303-17-5 OD42 1.4 Aranite 14D-57-8 035 NA EndmuNan 33213-65.9 OL29 . 013 Trite 75-25-2 0.63 IS alpha-BNC 319-846 000014 OD56 EndoraAfan sulfate 1031-07-8 0.029 0.13 2,4,6-Tribn n*henol 118-79-6 OD3S 7A beta-BHC 319.85-7 OD0014 0.066 Erdrin 72.20-8 0,0028 0.13 1,2,4Triddorobmmre 12D-82-1 0055 19 ddm-BHC 319-8" 0023 O.066 Endrin aldehyde 7421-934 O.025 0.13 1,1,1-Trichbradhane 71-55-6 00% 6D gamma-eHC 58.89-9 0.0017 0066 EPIC 759-94-4 0042 `,1.4 1,1,2-Trichbretlune 79-00-5 OA%- 6.0 i Barban 101-279 O4% 1.4 Ethyl acetate _ 141-78-6 0.34 33 Trichloroefhylene 7"1-6 0054 60 Bendiocab 22781-23-3 ODS6 IA Ethyl benzene IOD-414 OD57 10 Trichloromonofluoromethane 75-694 O.020 30 Bend cart,phenol 22%1-92-6 OD56 1A Ethyl cyarde/Popanentrile 107-12-0 024 350 2,4,5-Trdrloropherol 95954 OAS 7.4 Betw"I 1760435-2 0056 1.4 Ethyl ether 60-29-7 0,12 160 2,4,6-Trichkoophe of 88-06-2 0035 7.4 Benzene 7143-2 014 10 bis(2-Ethythexyl)phthalate) 117-81-7 028 28 2,4,5-Trirhlorophenoxyacetic Benz(a)anthrdcenes 56-55-3 ODS9 3.4 Ethyl methacrflate 97-63-2 0.14 160 acid 93-76-5• 0.72 79 Benzal dioride 98-87-3 O1055 60 Ethylene oxide 75-21-8 0.12 NA 1,2,3-Tnchlorapraparre 96-184 OAS 30 ll n (b)Oraranthere 205-W-2 0.11 62 Famphur 52-85-7 OD17 15 1,1,2-Trichlo -1,2,2tri- (difficult to dstrgtrdr from benzo(k)flara then) Ruorantt a 20644-0. Om 3A BswroeNwre 76-13-1 OD57•' 3D Benzo(k)Borzra dr 207-089 0.11 6.8 Ruarene 86-73-7 0059 3.4 Tnethylanine 10144-8 OD61 15 (diffWt to distkV sh from berzo(b)flouanthere) Formetanae hydrochloride 23422-53.9 0056 IA tris-(2,3-Dibronroprapyl) Benzo(g,h,i)perylme 191-242 0.0055 18 Fomgaianatr± 17702-57-7 0D56 1.4 phosphate 126-72-7 0.11 0.10 j Senzo(a)pyrare 50.32-8 0061 3A Heptachlor 7644-8 OW12 0.066 Vemolate 1929-77-7 0.042 1.4 j Bronndichloromefhane 75-274 0.35 15 Heptachlor epoxide 1024-57-3 O.016 OD66 Yrnyl chloride ' 75-014 027 6.0 BramrnetltaWMethyl brornde 74-M-9 0.11 is Hexachbrobenzene 118-74-1 0055 10 Xyleres-mixed corners(sum 4&ornophenyl phenyl.6- 101-55-3 OD55 15 Hexachlorbutadime 87.68-3 OD55 5.6 of o-,m-and p-xylme n-Butyl alcohol 71-36-3 5.6 2.6 Hexach6wydopmladence 77474 0.057 2.4 concentrations) 1330-20-7 032 30 "taw 200841-5 0042 1.4 HxCDDs(all Hexarhlorodbenzo lOa¢anic Cmitibmilts BW benzyl phlhahate 8568-7 0D17 28 p-dioxins) NA OA00063 0.001 Mtinony 7440-36-0 19 1.15 map TCLP 2sec-Butyl4,6-dndrepheroi HxCDFs(all Hexadrlorodbenzo- Arsenic 7440-38-2 1.4 5.0 mg/h TCLP /Dittaseb 88-SS-7 '•OD66 25 furans) NA OD00063 0.001 Barium 744D-39-3 .12 21 mg/I TCLP Carbaryl 6325-2 OA06 0.14 Hexachloroetlwre 67-72-1 O.055 _ 30 Berylliwn 744041-7 OA2 1.22 mg/I TCLP Carbenzadkn 10605-21.7 0056 1.4 Hexachirupropylen e '1MO.71-7 0435 30 Cadnirn - - 7440.43-9 0169 0.11 ngfi TCLP Cabofuran 1%3-W2 OAD5 0.14 Indeno(1,2,3-c,d)pyrare 193-39-5 0D05S 3.4 Chen riran(Total) 7440-47-3 2.77 0.60 mg/1 TCLP Catiofitran phew) 1563-38-8 O.056 1.4 Iodomethane 74-884 0.19 65 Cyanides(Total)4 57-12-5 12 590 Carbon disulfide 75-15-0 32 42 mg/I TCLP Isobutyl alcohol 78-83-1 S.6 170 Cyanides(Amenable) 57-12-5 O.86 3D j Carbon Tebachionde %-23-5 O.057 6.0 Isodrin 465.73-6 O.021 OD66 Ruoride s 1698448-8 35 NA Carbasulfan 55285-148 OD28 1A Isolan. 119-38-0 ODS6 1.4 Lead 743992-1 Ob9 0,75 r g/I TCLP Chlorodane(alpha and Isosafrole 120-58-1 0.081 2b Mercury-NWW from Retort 7439976 NA 020 mgp TCLP gamma isomers) 57-749 OD033 026 Kepone 143.50-0 0.0011 0.13 Memwy-All Others 7439976 0.15 O1125/ng/l TCLP p-ddoroarriline 10647-8 0,46 16 MethY 'lonitrite 126-%-7 024 84 Nickel 7440-02-0 398 Il mg/I TCLP Chlaobenzere SO890-7 OD57 6.0 Methanol - 67-%-1 5.6 - 0.75 mgjh TCLP Selenium x 7782-49-2 OA2 5.7 rrg/I TCLP Chloruberdlate 510-IS6 0.10 NA McNwpyriene 91-80-5 OD81 15 Sitter 744D-24 0.43 0.14 ng/l TQP 2-Chlon-1,3 bAadene 12699-8 OD57 028 Methioarb 203265-7 O456 1.4 Sulfide' 18496-2" 14 NA j Chbrodbromometlwne 12448-1 O.OS7 15 Methomy4 16752-77-5 OD28 1.14 Thalhum 744-28-0 1.4 024ngjt TCLP Chloroedane 75-00-3 017 6.0 Methoxychlor 7243-5 025 0.18 Vanadiun s 7440-62-2 43 lb mg/i TCLP Bis(2--Gdoroet w ry),nett ne 11191-1 OD36 72 3-MethVicholanthrere 5649-5 ODO55 is Zinc`- 7440-666 2.61 43 mg(I TCLP Bs(Z-Chloroefhyl)ether ill 44-4 OD33 6.0 4,4-Methylene bis(2-chlor nihkre)WI-144 OSO 30 - ! Chloroform 6766-3 0.046 6.0 Methylene chloride 75-09-2 0.069 3D Bs(2-Chkrr soprapYl)ether 3908-329 0D55 72 Methyl ethyl ketone 78-93-3 028 35 p-0rlomYrr<rgol 59-SD-7 ODIB 14 Methyl wbugl ketone 108-10-1 0.14 33 2•Qrbrcetheyl rinyl eher 110-75-8 OD62 NA Methyl methaaylate 80626 0.14 16D Chloronethane/Methyl chloride 74-87-3 0.19 30 Methyl rnethanszNonae 66-27-3 0DI8 NA 2-Chloronaphthalene 91-58-7 0D55 5b Methyl parathion M-00-0 0D14 4.6 i 2-Chlorophenol 95-57-8 OD44 5.7 MCMlrarb 132941-5 OD56 1.4 3-4rbmpropylere 1D7-05-1 OD36 30 Mexacarbate 315-184 O,056 1.4 Chrysere 218-019 0059 3.4 Molirmte 221267-1 0.042 1.4 ocsesol 9548-7 0.11 5.6 Naphthalene 91-20-3 OD59 5.6 mbesol(dfGaltto 2-Napthylomne 91-5941 052 NA distinguish from peresd) WO-394 0.77 5.6 O-Nitroan0nre BB-744 027 14 J p-Cresol(elf iC It to p-ntroaniine 1OD-016 oms 28 distinguish fium mcresol) 10644-5 0.77 5.6 Nitrdrerzene 98-95-3 0m 14 n-Cunveyl rtrethylarbonate 64-006 O.056 1.4 5-Nitro-o-bikzidne 99-55-8 OX 28 Cydohexanome 108.941 0.36 0.75 mg/1 TCLP o-Nitropherd 88-75-5 ome 13 op"-DOD 53-19-0 0.023 OD87 1,11bophew1 100-02-7 0.12 29 p,p`-DDD 72-S" OD23 OD87 N-Nitrosodiethylamire 55-18.5 0.40 28 o,p'-DDE 3424826 0D31 OD87 N-Niousadimethylarnim 62-759 OAO 23 p,p`-DDE 72-559 0.031 OD87 N-Nitroso-diyrbutylamire 924-16-3 0.40 17 j op•007` 789-026 ODD39 0.087 N-Nitrosomehyle0rylamine 10595956 0.40 2.3 p,p'-DDT 50.29.3 OD039 0067 N-Nitresomorphdine 59.89-2 0.40 23 Dibenz(a,h)anthrawne 53-70-3 0055 882 N-Nibosopperid"ne SOD-754 O.013 35 Dibenz(a,e)pyrere 192654 O461 NA N-Nftrasopyrdidne 930-55-2 0013 - 35 1,2-Dr"br 3drlorvproparK 96-12-8 0AI i5 (hmmyl 23135-22-0 0.056 028 ' 1,2-DiMarwethanej9hylene Parathion %-38-2 0014 4.6 dibronide 106934 0028 15 Total PCBs(scan of all PCB ' Dibrornernethane 74.95-3 0.11 75 isomers,or a8 Amck rs) 1336-36.3 0.10 10 mdidiaobenzene S41.73.1 0D36 6.0 PebLdate 1114-71-2 0.042 1.4 O-Dichlorberzen a 95-50-1 O.Ow 60 P ntaddorobe nzene 60893-5 0055 10 p-Didrlorobenzene SO646-7 ODW 6.0 PeCDDs(AII'PerrtacNoro libenw Oidrbrod8uoronreO erne 75-71.8 023 72 -p-diwrins) NA 0000D63 ODOL 1,1-DkWoroethane 7543-3 ODS9 6.0 PeCDFs(AB Peradrloro- 1,2-Didrbroelhane 107-W2 0.21 6.0 benzahnns) NA 0.000035 ODDI 1,1-Dichloroefhylere 75-354 OD25 6.0 Pentachiorcethane 76-01-7 OASS 6.0 bans 1,2-Didloroehylme 1566D-5 O,054 30 Pentafibronitrobenzene 132-6" 0D55 42 2,4DichWopherd 120-83.2 OD44 14 87416-5 O489 7.4 2f-DkhWropWW 8765-0 00" 14 Wrmaoetin 62442 O.081 16 2,4Dirhbropharoxyaatic Mverwint rene 85-01-8 OAw SA ' scid/2,4D 94-75-7 0.72 10 Rrerol 1011195-2 OD39 62 1,2-Oifibropmpan a 78-97-5 OAS i8 o-phmylexd'amine 95.54-5 OD56 5.6 ds-1;-Oiohlorpropylene MMI-01-5 0036 38 Phal 298-02-2 0021 4A trans-1,3-Diddavaopylene 10061.026 O.036 is RNhaec add IOD-21-0 0D55 28 Dklddn 60-57-1 0,017 0.13 NMaBc arihythide SS-449 OASS 28 WAh*re gfycd,diarbanute 5952-26-1 OD56 L4 Rn 50dill a 57476 O1156 L4 OieM1111 001aiae 84.66.2 02D 28 Rrysstionite-kyl- 57647 0056 1.4 -Oerethylanmoazaheuene 60-11-7 0.13 NA Pam b 2631-37-0 0.0% IA 24.Obbhyl phenol WS679 OD36 14 Ponatide 23950.5&5 0093 1.5 Dbreft phtha6te 131-11-3 OD47 28 hopham W-09 0D56 IA DineBmn 644.644 OD56 1.4 Popoxw 11t26.1 0056 1A 0i-n'bW pdtlaLate 84-742 OD57 28 Pnoadfoorb SQ888-809 Doe IA 1,4 dntbabenzerte I00.ZS4 0.32 2.3 F!Y- 129.00.0 0.067 8.2 4.,.DINfro-o0VW 534.52-1 0.28 160 Pyrka- 1104wi 0.014 16 2,4a1nitrophetol 51-28-5 0.12 160 safrok 94.59.7 0.081 22 (2) SPENT SOLVENT WASTE CONSMUENTS Circle applicable waste code(s)and consfituent(s)for each manifest line item containing EPA spent solvent waste codes F001-F005. s A B C D F001 ABCD F002 A B C D F003 A B Cj D F004 A B C D F005 ABCD -acetone A B C D -ethyl ether A B C D -benzene ABCD -methanol ABCD -n-butyl alcohol A 8 C D -methylene chloride ABCD -iso-butyl alcohol ABCD -methyl.ethyl ketone ABCD -carbon disulfide ABCD -methyl isobutyl ketone ABCD -carbon tetrachloride ABCD -nitrobenzene ABCD -chlorobenzene A B C D -pyridine ABCD -m-cresol ABCD tetrachloroethylene ABCD -o-cresol ABCD -toluene ABCD -p-cresol A B C D_-1 1 1,1-trichloroethane ABCD -cresylic acid A B C D -1,1,2-trichloroethane A B C D 7cyclohexanone ABCD -trichloroethylere ABCD o-dichlorobenzene ABCD -trichloromonofluoromethane ABCD -ethyl acetate A B C D -1,1,2-trichioro-1,2,2-trifluoroethane .ABCD -ethyl benzene ABCD -xylenes (3) UNDERLYING HAZARDOUS CONSTITUENTS For characteristically hazardous waste streams(EPA codes D001--DO43),please list all underlying hazardous constituents as defined in 40 CFR 268(2)(i)that are present at concentrations exceeding.the universal treatment standards listed in 40 CFR 268.48(F001-FOO5 constituents identified in section(2)and specific constituents for EPA U-, P-,and D004-DO43 codes listed in section(1)do not need to be listed in this section). A. None Present A. None Present A. None Present A. # None Present (4) HOW MUST THESE WASTE STREAMS BE MANAGED? For each manifest line item,circle applicable treatment/requirement. For contaminated soil,circle applicable choice as indicated. ABCD_This waste is non-hazardous per 40 CFR 261,and is not restricted from land disposal under 40 CFR subpart D. C D_This is',an EPA hazardous waste that is not a contaminated soil or hazardous debris. Waste must be treated to the appropriate treatment standard set forth in 40 CFR subpart D prior to land disposal A B C D_This is a hazardous debris(>60mm/2.36 inch)and is subject to the alternative treatment standards of 40 CFR 268.45. A B C D_This is a hazardous waste contaminated soil. This contaminated soil does/does not(d"1°0fl)contain listed hazardous wastes and does/does not(d10le 0m) exhibit a characteristic of hazardous waste and is subject to/complies with Marcie"*)the soil treatment standards as provided by 268.49(c)or the universal treatment standards. A B C D_This is an EPA hazardous waste that meets all applicable treatment standards set forth in 40 CFR 268 subpart D, and can be landfilled without further treatment. I certify under penalty of law that I have personally examined and am familiar with the waste through analysis and testing or thorough knowledge of the waste to support this certification that the waste complies with the treatment standards specified in 40 CFR Part 268 Subpart D and all applicable prohibitions set forth in 40 CFR 268.32 or RCRA section 3004(d). I believe that the information I submitted is true,accurate and complete. I am aware that there are significant penalties for submitting a false certification,including the possibility of a fine and imprisonment. (5)CERTIFICATION I certify that all Information on this and all associated documents is complete and accurate to the best of my knowledge. Signature: _ Title: Printed Name: Date: LOCATION SEWAGE PERMIT NO, 118c� Hof VILLAGE I N S T A LLER'S NAME ADDRESS J70- 4, /9 5-61 B U I L D E R OR OWNER D A T E P E R M I T ( fS U E D ��- DATE COMPLIANCE ISSUED ���� i.� �t / ��� � � � j � / r i I Il� / `d io � �� r I� I � 'I ' @ � �, .e.. �. 9 - � ��' .e c .s ... � .� \6r1 � �� .R No— ...../.. F � ps .............. .�........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ........:.......... ...........OF..........................------.......-----._...------......._..---......._............-_ Appliratiou for Uiopoottl Workii Towotrur#ion "rrutit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: 9 .... � s.... -�1 - ..................... Loca n•Address W /J ;/� or Lot No. lJ" Owner Address 4, �S1 Ufa •.:.................••-•--•-•---......_......'..___-��•-•......-••-•-•._ ..---••-•-�•- Installer Address crJ Type of Building !�f/� �zC�u✓�r��� `3vic Size Lot............................. -€eet 1 Dwelling No. of Bedrooms�R G________________________________Expan i n Attic ( ) Garbage Grinder ( ) A4 Other Type of Building _______________g.____._._. No. of persons_____........................ Showers (X) — Cafeteria ( ) a Other fixtures ------�,trr`�lions---•-•.•--•••----ri-•-er da-----Total dail flow.__.___.____••-, .......................Flow WSeptic Tank—Liquid capacity/ q__gallons Length................ Width................ Diameter.........._..... Depth................ x Disposal Trench—No.-Ye.!` Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter_. 1_.._..__..._ Depth below inlet...... Total leaching area..................sq. ft. Z ,Q:ther Distribution box (X ) Dosing tank ( ) s Percolation Test Results Performed by...ST_E_P_Nglil_..SE_YM.QYA..�______________________ Date..... �. _S_._._.....__.. as Test Pit No. 1.L_:._ ._minutes per inch Depth of Test Pit-----!.Z__....__.. Depth to ground water._oAi:�.......... Test Pit No. 2...l<_:__n inutes per inch Depth of Test Pit......1..!�......... Depth to ground water---No. Z........ p4 ----------------- -----•---•--•---•----------------------------------------- •....... ••-••--•••-••-•------- •------- •-•••- -------------- ODescription of Soil.......-,CUl.3j'-` .. I. �?��4-��.......__QAP__T-H__.�'-�•••••-•-••--•••••----------•-••-••-••....-----•••••••-•-••-•••••••••-•••----...-----•-•- Il'1�A�.ut?1 �.r�t�L Q 4 �� v�L--------•--•jaPT ._...!.° (� ---....._._ _ ................•-•-----••-•----••••••-•-•--•-••---••----------•----_____---._..___. -••••••••-••---- --•-------------••••••••--••••-••••---•-----......_._---•-•------••----------•-•---. •••-•--••-••--••---•---- U Nature of Repairs or Alterations—Answer when applicable______.�1 ___ _ _ 1___�_____________________ cz. Agreement: The:undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with r` the provisions of iITLi� 5 of the State Sanitary Code—.The undersigned further agrees not to place the seem in operation until a Certificate of Compliance has n iss a by the b•and of health. y-/ Signed........ .......................... �) J C ' ate t �^ Q.S Application Approved By..... ..___...:�.__'._.. . l_-__a .... Date Application Disapproved for the following reasons:----••---------•--••-------•----•••••--•-•-••••••-••-••••••••••-•--•---------------•-----•-----------........._ ...................•..._.._...--•-------••-••--••---••••.._..........-•••--•----•------..._._..------•---.._-------------...._._....._..______.______-••••--•---..-.-.----------•-•-•-------•--•-...----- Date Permit No.... r ..............//-��-- --------------------•-----._.... Issued..------- - -•----._ Date - - __. ---- - -------------------------------- No, .- .... FE$.................�....... THE COMMONWEALTH OF MASSACHUSETTS :BOARD OF HEALTH .........._....OF.......................... A#Vliration for DhT oat Works Tonotrnrtion ramit Aplicatioi is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --..............--.............................................................................. ----•....._...........•--......... ............................................. -•--•---...............---• ------... Location-Address or Lot No. ......................—.......................................................................... . ..........•••....--•.......••----............_........---.....---••-............._................ Owner A ress �-J- .............................•--------_------ ---J----•------------------------•---•---•---�---•--'----`--- ............ •� Installer Address L f Type of Building ,,w�rc �.Jolr4ci, v��r°i Size Lot............................. lr"j�t ,., Dwelling—No. of Bedrooms.......................:....................Expansion Attic ( ) Garbage Grinder ( ) '4 e of Building ............. — a Other—T YP g -------------- .. No. of----•-----...-•--P--ersons....................___.._._ Showers- (?C) Cafeteria ( ) Other fixtures-___.pr! _ _.__...._ -----------------------------------------•------•-----------------.-.-•-----•--•---------._.. W Design Flow...................................�P' �m/gallons Ali per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth x Disposal Trench` No -------------- Width.................... Total Length.................... Total4iaching.,area............. :;.sq. ft. Seepage'Pit No.- ----- _----- Diamete = ; . DePth °beo `inlet.................... Total leachig` area . _ q. ft. Z Other Distribution box O Dosing"tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1.G'...�7..minutes:per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2--- _ �'!niriut,es:per inch Depth of Test Pit.................... Depth to .ground water........................ ...........................................................:-------•--...------....-------•--......................................................... ODescription of Soil...........---•-----------------•--------------.....t...I.............................................................................................................. ., ,.,.. . c, ...-------- x ........................................................ ..•.••-•••-•-----•----••••---•••••-••••-•---•---•••-----------•--•---~� • •--••-••---••_..... U Nature of Repairs or Alterations—Answer when applicable-_____-PUD---- 1� .............••.•.... I -- Agreement: The undersigned ,agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITI.%, . 5 of the State Sanitary Code—.The undersigned further agrees not to place the :9em in operation until a Certificate of om liance has been issued b the board of health. y�.l _ P P Y Signed -•---•---------•-----•-------•----•----•--•---------------------------------- ---------- -------•---•------- Application Approved BY ---• ` i = ........................................Dat r /c Application Disapproved for the following reasons---------------••-----...-------------------------------------------------------------------•-••-............--- ••......•••-•••••-••-•--••---•-•------••-••-•.•••--••-•---....-•--•----•---•--•-•--••._...••----••-••-.....-••-•-••----•-----•••............••---••••--•--•------••••••--............................... r^ Date Permit No....j� /n,.....•.................. .._ ... Date THE} COMMONWEALTH OF MASSACHUSETTS t f—�1.� i' �+w �+�P �._.- B'OARD--.OF HEALTH ............p`^� ....OF............ :R��.4 ->.t^�Cc 01rrtif iratr of Tomplittnrr THIS IS T Y, .._CERTI T at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..--••-........`�—�"' Y:1...... ..... scaii ----- ------------•--•-•--.............----•----........------....--•----•---- -• •-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code descr]'bed in the application for Disposal Works Construction Permit No.... .."-_�8. ,.... dated.....__1_.'__ 2- t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... ................................. .. Inspector THE COMMONWEALTH OF MASSACHUSETTS � ; fN BOARD OF HEALTH- CCC�5y1 s� .. ..... ....... `? .............OF..*..... ... am ' — .......----••• FEE........................ io �a tt1 orko Cron trudwit Vrrmit Permission is hereby granted.........:,.�--. n .. --------•------------------------------------------------•--•-•--•........ to Construct ( ) or a ap,�ir ( ) an Individual Sewage Disposal System atNo. ............................................................... �---------............................................................................ Street ` as shown on the application for Disposal Works Construction Permit No. ..._�:��-'Dated.._._..�.�/_2'_�-��-?' r - ............. ............ �y Board of Health DATE...........! • -••`` ��-J` zS�......--••......••-•-••••• Y FORM 1255 A. M- SULKIN, INC., BOSTON - {