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HomeMy WebLinkAbout0093 PHEASANT WAY - HAZMAT g3 Pheasant w4� , 7 U �� BENNETT ENVIRONMENTAL ASSOCIATES, LLC. A NATURAL SYSTEMS UTILITIES COMPANY LICENSED SITE PROFESSIONALS * ENVIRONMENTAL SCIENTISTS *GEOLOGISTS * ENGINEERS 1573 Main Street,Brewster, MA 02631 * 508-896-1706 * Fax 508-896-5106 * www.bennett-ea.com LETTER OF TRANSMITTAL TO: DATE: JOB NUMBER: Mr. Mark Schindler 4/14/21 K11358 93 Pheasant Way A- Centerville, MA 02632 REGARDING: DIESEL FUEL SPILL Roadway Release SHIPPING METHOD: In Vicinity Of(IVO)93 Pheasant Way Centerville, MA Regular Mail Pick Up Priority ❑ Mail ❑ Hand Deliver ❑ Express Mail ❑ Other ❑ Certified Mail ❑ Green Card/RR ❑ COPIES DATE DESCRIPTION 1 4/14/21 Diesel Fuel Spill Report- Roadway Release 1 2/16/21 COMM Fire District Incident Report[2021-000562] & 1 photo 1 2/16/21 BWSC 101 MA DEP Release Log Form 4 2/16/21 Photo Documentation 1 4/7/21 Uniform Hazardous Waste Manifest[023019877 JJK] For review and comment: ❑ For approval: ❑ As requested: ❑ For your use: REMARKS: cc: COMM Fire District-Brian Morrison, Captain Barnstable;Boardbf.Health=Hazardous-Materials Anthony_Gerace J FROM: John Tadema-Wielandt, LSP, Manager of Environmental Services/dmk If enclosures are not as noted,kindly notify us at once 133ENNETT ENVIRONMENTAL ASSOCIATES, LLC. A NATURAL SYSTEMS UTILITIES COMPANY LICENSED SITE PROFESSIONALS 6 ENVIRONMENTAL SCIENTISTS 6 GEOLOGISTS ® ENGINEERS 1573 Main Street, Brewster, MA 02631 6 508-896-1706 ® Fax 508-889-5109 ® www.bennett-ea.com Job#K11358 April 14, 2021 Mr. Mark Schindler 93 Pheasant Way Centerville, MA 02632 RE: DIESEL FUEL SPILL Roadway Release In Vicinity Of(IVO) 93 Pheasant Way Centerville, MA Dear Mr. Schindler, On February 16, 2021, BENNETT ENVIRONMENTAL ASSOCIATES, LLC (BEA) responded to the above-referenced location at your request, to assist in the cleanup of a small diesel fuel spill. You reported that your vehicle, a 2014 BMW 328d station wagon, was discovered leaking diesel from a fuel line while parked in front of the subject property. The car was towed from the scene and repaired. You later contacted the Centerville-Osterville-Marston's Mills (COMM) Fire Department to report the diesel fuel spill. COMM Fire personnel responded to the scene and applied granular absorbents to absorb the remaining fuel from the pavement, and to prevent the fuel from spreading. Fire Department personnel reported that due to the melting snow and rain, that the fuel was traveling down the street in a southwesterly direction, approximately 300 feet, towards the direction of the Centerville River. COMM Fire personnel then contacted the Massachusetts Department of Environmental Protection (MA DEP) to report the release. MA DEP personnel recorded the incident in a Release Log Form and assigning Release Tracking Number (RTN) 4-28687. However, the Release Log indicated that the reported release was less than the Reporting Thresholds, pursuant to the Massachusetts Contingency Plan (MCP). MA DEP personnel further notified the Massachusetts Division of Marine Fisheries regarding the spill in the area of the Centerville River. Town of Barnstable Board of Health personnel (Anthony Gerace) also responded to the scene to review site conditions and recommend additional cleanup. You then contacted BEA to provide a response for additional cleanup. BEA personnel responded to the site that afternoon and met with you to review the circumstances.surrounding the fuel spill and document site conditions. Upon arrival at the site, BEA observed areas of stained asphalt covered with granular absorbents. Due to wet conditions and melting snow, a petroleum sheen was observed emanating from these areas and running 1 EMERGENCY SPILL RESPONSE ® WASTE SITE CLEANUP • SITE ASSESSMENT ® PERMITTING & SEPTIC DESIGN&INSPECTION DESIGN BUILD ® OPERATION&MAINTENANCE 06 WATER SUPPLY DEVELOPMENT WASTEWATER TREATMENT 16 FIELD SERVICES APRIL 14,2021 SCHINDLER-RTN 4-28687/K11358 PAGE 2 OF 3 DIESEL FUEL SPILUIVO 93 PHEASANT WAY,CENTERVILLE,MA down the street in the direction of the Centerville River. BEA personnel placed absorbent pads in the gutters on the side of the roadway to capture any migrating fuel. The spent absorbents applied by COMM Fire were recovered and placed into '55-gallon DOT drums. BEA personnel applied an additional 9-bags of granular absorbents to the areas of heaviest staining. Snow and ice that appeared contaminated with fuel was also placed in drums for later off-site disposal. The area of heaviest staining measured approximately 10' x 12' and was located off the street, in front of the dwelling. According to you, this area corresponded to where the vehicle was parked when the leak was discovered. Smaller areas of staining were observed to the north and west, where it appears the car was moved when the leak was active. BEA personnel inspected the pavement in the areas of heaviest staining, which appeared in good condition with no significant cracks or perforations noted. After recovering and drumming the spent absorbents, the petroleum sheen had dissipated. BEA personnel inspected conditions at the bottom of the hill on Pheasant Way in the vicinity of the Centerville River. BEA observed a non-persistent sheen on a puddle within the roadway and applied absorbent pads to recover the petroleum on the puddle. No free product or petroleum sheen was observed in the wetlands off the roadway. No assessment activities were conducted to qualify the presence of diesel fuel in subsurface soils or impact to nearby wetlands. The estimated volume of fuel released is 2 to 3 gallons. This estimate is based on information provided by you, that the vehicle's fuel tank was slightly over 1/4 full prior to the fuel spill, and between 1/4 and 1/8 full after the fuel spill. As such: Wherein the capacity of the vehicle's fuel tank is 15.0 gallons. And 15-gal x 1/4 = 3.75 gallons. And 15-gal x 1/8 = 1.875 gallons. And wherein 3.75 gal— 1.875 gal = 1.875 gallons Therefore, the estimated volume of the fuel spill was 1.875 gallons. On April 7, 2021, three drums of spent absorbents, were transported off-site. to CycleChem in Elizabeth, NJ, for disposal. The Uniform Hazardous Waste Manifest is enclosed for reference. The emergency response actions conducted were performed to recover a small volume of diesel fuel from a paved roadway. Response actions included application and recovery of absorbent materials, which were later disposed of off-site. The volume of the release is estimated at 2-3 gallons and is below the reportable quantity threshold under the governing regulations. As such no Release Notification condition is apparent. No assessment activities were conducted to qualify the presence of diesel fuel in subsurface soils or impact to nearby wetlands. The proper disposal of spent absorbent materials further document regulatory compliance, wherein these materials were transported to the appropriate receiving facilities under the applicable regulatory guidelines. I If you have any questions or need additional information,please contact me.directly,at. your earliest convenience. APRIL 14,2021 SCHINDLER-RTN 4-28687/K11358 PAGE 3 OF 3 DIESEL FUEL SPILUIVO 93 PHEASANT WAY,CENTERVILLE,MA Sincerely, BENNETT ENVIRONMENTAL ASSOCIATES, LLC 0i � W_ J J4 D. Tad ma- andt, LSP R ry Tri ble MAnager of Environmental Services Project Manager Encl. -COMM Fire District Incident Report [2021-000562] -BWSC-101 MADEP Release Log Form -Photos -Uniform Hazardous Waste Manifest [023019877 JJK] Cc. COMM Fire District—Brian Morrison, Captain Barnstable Board of Health—Anthony Gerace NFIRS-1 A COMM FD 02/16/2021 10:18:00 2021-000562 00 Fire Department Date Time Incident Number Exposure Basic B In front of 93 PHEASANT WAY Apt or Room A CENTERVILLE, MA 02632 census Tract C Incident Type: 411 E 1 Dates and Times E 2 Shift and Alarms Gasoline or other flammable liquid Alarm Time 02/16/2021 10:18:00 spill 2 1 COM12 Time Out 02/16/2021 10:19:00 Shift Alarm District Alarm Box D Mutual Aid: None Arrival 02/16/2021 10:23:00 E 3 Special Studies Their FDID State Incident Controlled Cleared 02/16/2021 11:13:00 Responding Departments(Press other) F Actions Taken: 82 , 44 Gi Resources AppaGius Personnel . G2 Estimated Dollar Losses 1. Notify other agencies. S Losses 2. Hazardous materials leak control& Suppression 1 3 containment EMS 0 0 Property Unknown Other 1 1 Contents Unknown Personnel Not on Apparatus 0 Pre Incident Value Total Personnel 4 Property Unknown Contents Unknown Hi Casualties Deaths Injuries H3 Hazardous Materials Release .J Property Use Fire Service 0 0 1 or 2 family dwelling Civilian 0 0 H2 Detector I Mixed Property Use K1 Person Entity Involved K2 Owner MARK SCHINDLER 93 PHEASANT WAY CENTERVILLE, MA 02632 L Remarks UNKNOWN AMOUNT OF DIESEL FUEL LEAKED FROM VEHICLE INTO DRIVEWAY REQUEST 306 FOR MORE SPEEDY DRY AND TRASH BAGS. 306 WILL BE COMMITTED STA 1 STANDBY IS CARPENTER, GELINAS, HAMMOND DEP HAS THE MESSAGE WILL CALL CAPTAIN. Unknown amount of diesel spilled down road 306 able to contain any more from running into Centerville River. DEP advises homeowner to contact insurance company and cleanup company, DEP will also advise Marine and Fisheries. User:WMonroe 2/16/2021 11:18:00 Responded to investigate a spill of diesel fuel. C-321 arrived on location and met with the owner. Owner stated his vehicle leaked diesel fuel. Vehicle has since been repaired. Fuel was spilled in multiple locations on the driveway and on the pavement in front of the house. Due to melting snow and rain,fuel was traveling downhill approximately 300 feet in a westerly direction and into the area of the Centerville River. The approximate amount of fuel spilled is estimated to be 5-10 gallons. E-306 was requested to the scene. Advised dispatch to notify DEP. Spoke with Elsa at DEP. They advised to have the owner contact his insurance company and a clean-up company. DEP would notify Marine and Fisheries. E-306 arrived on location and placed 6 bags of speedi-dry down to contain the diesel fuel to the driveway/roadway area. E-306 returned to quarters.Advised the owner to contact his insurance company. C-321 returned to quarters.User: BMorrison 2/16/2021 12:59:10 C-321 while in quarters notified Town of Barnstable Board of Health. Anthony Gerace from BOH responded to the scene. C-321 responded to meet with the BOH. Met with the owner. Owner stated he contacted his insurance company. BOH recommended a local cleaning from Orleans to respond. ETA 30 minutes. C-321 also 9 company p Y spoke with Town of Barnstable Natural Resources. Date:02/25/2021 Centerville-Osterville Marstons Mills Fire Page: 1 Vehicle: Grey BMW 4 door Ma Reg 145 VC2 Insurance Company: Geico User: BMorrison 2/16/2021 13:03:00 M BRIAN MORRISON Captain 02/16/2021 Officer in Charge Rank Assignment Date BRIAN MORRISON Captain 02/16/2021 Member Making Report Rank Assignment Date R SS Special Studies ID Title Entry Description 9244 COVID 19 Discovery No,COVID 19 was not a factor. J Date:02/25/2021 Centerville-Osterville Marstons Mills Fire Page:2 t t r� , -7 7 "t� — 1�_� 5.,+Faye. �fF ¢s r • - ' � a . PAW PAW' ,!{} eF - 4 T ' u �•Y1 • ,Y ;fig. s 6� TT.:• .4 „u �id ,��ayF��7F�a_.f �"tJ �.� s .�. � k 'rt�'1..c€ �t�` •f 'i F f Massachusetts Department of Environmental Protection BWSC 101 ` Bureau of Waste Site Cleanup �F Release Tracking Number RELEASE LOG FORM A.THIS FORM IS BEING USED TO: (check one) 1.Log Date: 2/16/2021 Log Time: 12:49 r AM W+PM (mm/ddlym) (hh:—) V 2.Assign a Release Tracking Number(RTN)to a Release or TOR Report. rj a.Reportable Release or TOR. r b.Release that is Less Than the Reporting Thresholds. r,3.Amend a Previously Recorded Release or TOR Report(RTN Assigned). r!a.The Release is a Reportable Release or TOR. r,b.The Release is a Release that is Less Than the Reporting Thresholds. r-J c.The Release or TOR is Retracted. r d.The Release or TOR is not a Release under M.G.L.c.21E. (BWSC103 must be submitted,as well) B.REPORTING PERSON: 1.Name of Organization: CENTERVILLE FIRE DEPT 2.First Name: BRYAN 3.Last Name: MORRISON 4.Telephone: 5083676560 5.Ext.: 6.Relationship of Person to Release: r!PRP rv1 Other c.Type,if known(e.g.Current Owner): Municipal Fire Dept Official C.RELEASE OR THREAT OF RELEASE(TOR)/SITE LOCATION: 1.Location Aid/Site Name: PHEASANT WAY 2. Street Address: 93 PHEASANT WAY 3.2nd Address Line: 4.City/Town: CENTERVILLE,BARNSTABLE 5.Zip Code(if known): 6.Type of Location:(check all that apply) F a. School r-b.Water Body r!c.Right of Way r d.Utility Easement r e.Roadway r.f.Municipal r g. State r,7 h.Residential r7 i.Open Space RI j.Private Property r,k.Industrial r 1.Commercial r m.Federal r-,n.Other Describe: D.RELEASE OR TOR INFORMATION: 1.Date and Time of Notification: 2/16/2021 Time: 10:43 V.AM r'PM (nm/ddiyyyy) (nb:—) 2.Date and Time Reporting Person obtained 2/16/2021 Time: 10:43 17 AM r!PM Knowledge of Release or TOR: (mm/dd/yyyy) (hh:mm) 3.Date and Time Release or TOR Time: r AM rI PM occurred,if known: (mm/dd/yyyy) (hh:mm) 4. Sources of the Release or TOR:(check all that apply) f®,a.Transformer rJ�b.Fuel Tank r.c.Pipe r d.OHM Delivery r-e.AST rl f.Drums r g.Tanker Truck r+h.Hose r i.Line r1 j.UST Describe r.k.Vehicle 1.Boat/Vessel �i m.Unknown ri n.Other: 5.Federal LUST Eligible: ri Yes FF No rI Unknown Revised:01/07/2014 Page 1 of 5 Massachusetts Department of Environmental Protection BwsC 101 Bureau of Waste Site Cleanup RELEASE LOG FORM Release Tracking Number L r 28687 Check all Notification Thresholds that apply to the Release or TOR: 6.2 Hour Reporting Conditions: 7.72 Hour Reporting Conditions: 8. 120 Day Reporting Conditions: r a.Sudden Release r!a.Subsurface Non-Aqueous r a.Release of Hazardous Material(s) r;b.Threat of Sudden Release Phase Liquid(NAPL)Equal to Soil or Groundwater Exceeding r-c.Oil Sheen on Surface Water to or Greater than 1/2 Inch Reportable Concentration(s) ri d.Poses Imminent Hazard r b.Underground Storage Tank b.Release of Oil to Soil Exceeding r,e.Could Pose Imminent Hazard (UST)Release Reportable Concentration(s)and r�f Release Detected c.Threat of UST Release Affecting More than 2 Cubic in Private Well d.Release to Groundwater Yards g.Release to Storm Drain near Water Supply r c.Release of Oil to Groundwater r!h.Sanitary Sewer Release rI e.Release to Groundwater Exceeding Reportable (Imminent Hazard Only) near School or Residence Concentration(s) r!f.Substantial Release Migration r d. Subsurface Non-Aqueous Phase Liquid(NAPL)Equal to or Greater than 1/8 Inch and Less than 1/2 Inch 9.Type of Release or TOR:(check all that apply) ri a.Dumping r b.Fire r c.AST Removal r d.Overfill ri e.rupture r f.Vehicle Accident W,g.Leak r h.Spill r,i.Test Failure r j.TOR Only rt k.UST Removal Describe f 1.Unknown r—m.Other: 10.Media Impacted and Receptors Affected:(check all that apply) W a.Paved Surface r b.Basement r c. School r�d.Public Water Supply V e.Surface Water r f Zone 2 r,g.Private Well r h.Residence r.�i.Soil r j.Ground Water r,k.Sediments r 1.Wetland r m.Storm Drain r n.Indoor Air r o.Air ri p.Soil Gas r.q.Sub-Slab Soil Gas r.r.Critical Exposure Pathway r s.NAPL 17.t.Unknown r7 u. Others Specify: 11.List below the Oils(0)or Hazardous Materials OEVI)that exceed their Reportable Concentration(RC)or Reportable Quantity(RQ)by the greatest amount. Check here if an amount or concentration is unknown or less than detectable. O or HM Released CAS Number, O or HM Amount or Units RCs Exceeded,if Applicable if known Concentration DIESEL FUEL O 3 GAL N/A N/A N/A Revised:01/07/2014 Page 2 of 5 Massachusetts Department of Environmental Protection $WSC 101 Bureau of Waste Site Cleanup L RELEASE LOG FORM Release Tracking Number 4 28687 12.Description of Release or Threat of Release(if additional space is needed,attach additional information in 1117) DEP ER ON CALL PERSONNEL WAS INFORMED BY CENTERVILLE FD REGARDING A DIESEL FUEL LINE SPILL FROM A PASSENGER VEHICLE THAT WAS PARKED IN THE DRIVEWAY.THE CAR IS A BMW 4-DOOR SEDAN AND THE ESTIMATED AMOUNT IS 23 GALLONS.THE SPILL IMPACTED THE ROADWAY AND DOWNGRADIENT INTO THE NEARBY CENTERVILLE RIVER.VEHICLE OWNER CALLED DEP AND INFORMED DEP THAT HE FILED A CLAIM WITH HIS INSURANCE COMPANYAND THEY WILL PERFORM A CLEANUP. DEP ALSO NOTIFIED MARINE FISHERIES OF THE SPILL INTO THE RIVER. E.INVOLVED PARTIES SUMMARY: 1.PRP Status(check one): r a.PRP Unknown r b.PRP unwilling,unable or has not committed to Perform Response Actions W c.PRP Performing Response Actions r7l d.Release is Adequated Regulated by the US Coast Guard 2.If PRP is not Performing Response Actions,who is? r-a.MassDEP State Contractor r b.Other Person 3.Contractor: a.Name of Organization: b.Telephone: c.Contact First Name: d.Last Name: 4.LSP: a.Name: b.LSP#: c.Telephone: Revised:01/07/2014 Page 3 of 5 Massachusetts Department of Environmental Protection BWSC 101 y= Bureau of Waste Site Cleanup RELEASE LOG FORM Release Tracking Number 4 , 28687 F.PRP OR PERSON PERFORMING RESPONSE ACTIONS: 1.Name of Organization: 2.Contact First Name: MARK 3.Last Name: SCHINDLER 4.Street: 93 PHEASANT WAY 5.Title: , 6.City/Town: CENTERMLLE 7.State: MA 8.ZIP Code: 026320000 9.Telephone: 6172300302 10.Ext: 11.Email: 12.Relationship of Person to Release: r PRP 1 Other c.Type(e.g.Current Owner): Current Owner rl 13.Check here if this PRP received a field NOR r;14.Check here if an RNF was requested from this PRP r'15.Check here if Provisions of 21E were explained to this PRP. G.RECORD ORAL RESPONSE ACTIVITIES: r 1.IRA Completed Pre-notification r 5.IRA Oral Modified Plan Approved r 2.No IRA Approved at Notification r 6.IRA Oral Plan Denied and/or Request for Written Plan r.3.IRA Assessment Only. r 7.Notice of Intent to Conduct a URAM h 4.IRA Oral Plan Approved r 8 IRA-D Oral Plan Approved r-9.IRA-D Oversight Work Started 10.Date of Action: 11.Soil Previously Excavated: I`a.Excavated prior to notification. r b.Excavated as part of an UST closure. c.Quantity of contaminated soil previously excavated and destination,if applicable: 12.Specify any Regional Specific Code(Regional Use): H.ORAL RESPONSE ACTION PLAN: (check all that apply) 1.Assessment and/or Monitoring Only r 2.Temporary Covers or Caps r 3.Deployment of Absorbent or Containment Materials rJ 4.Temporary Water Supplies r.5.Structure Venting System r16.Temporary Evacuation or Relocation of Residents r7 7.Product or NAPL Recovery r 8.Fencing and Sign Posting 17 9. Groundwater Treatment Systems r 10.Soil Vapor Extraction 11.Bioremediation r,12.Air Sparging r7 13.Excavation of Contaminated Soils r1 a.Re-use,Recycling or Treatment r1 i.On Site 17 ii.Off Site Authorized volume in cubic yards: r�b. Store r'i.On Site r!ii.Off Site Authorized volume in cubic yards: rI c.Landfill r i.Cover r;ii.Disposal Authorized volume in cubic yards: Revised:01/07/2014 Page 4 of 5 Massachusetts Department of Environmental Protection $wSC 101 Bureau of Waste Site Cleanup RELEASE LOG FORM Release Tracking Number r 14.Removal of Drums,Tanks or Containers: Describe Quantity and Amount: r 15.Removal of Other Contaminated Media: Specify Type and Volumes r.16 Other Response Actions and Additional Comments(describe): IS 17.Check here if Additional Information is Provided in an Attachment I.DEP STAFF AND FORM PREPARER: 1.DEP Staff: a.Name: BYSTROM ELZA rI b.Check here,if Unassigned(or staff name not applicable). 2 .Preparer: a.Name: BYSTROM ELZA b.Signature: ELZA BYSTROM a Date: 2/16/2021 Revised:01/07/2014 Page 5 of 5 • - �.�„� ,sr,�.�. .sir •a.���:.•-.sir` *' �, " S . �'- oa 41. al 1 ^7t IL AA' rr"" ffla, NM ,.• Sa-.,t �. * .� , qF- R. �"44 •�.� a+r ,.w. ��t.. �. � � i4' a. _ :�'Jc :. d. ,*a 1 a •x �� N s, s ar :. yam, r"••'` ' n� as ; a as 7,.��' � : i?h '' `�•` � `:.n ^'"fir �1•:°''��.`�:.' ��` •. ~ � Sy �`v�,w'n � .G��, `�`r",_�� 4 w '^ - "'aT' '*^s".�,�. z w N ,a �ray a� "f r �r A`;.a`i •`, .4. .� e *�9,���� ` � «- �,.� .� „�,r � mow,,. �, .• ". � � ' �. �� �u w t,,�,.a.y .� -, s v d �• �,P ^�-w�'�':+" ,Y �C,.� a'.. 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Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1'GanaratorlD Number 2.Page 1 of 3.Emergency Response Phone 14.Mvftd Tr&ddng Number WASTE MANIFEST MA#tOOM2741 ,- 1 9t18-3S4-0210 0 2�O 1 9877 JJ K I 5.GeneerrapWss Name and �Meffsng Address Generators Site Address(if different than mailing address) 6.Transporter 1 Company Name U.S.EPA ID Number -'AOV ENYMNMM.W. IERNI CES.N+I r ;>.,; ', _ :,, :...... NJDD038IM47 7.Transporter 2 Company Nome U.S.EPA ID Number i i 8.Deslgnated Facility Name and Site Address U.S.EPA ID Number CYCLE CHEi tir.aNC:.:.::r. :... ; :a;:,:zs: ;i i::: .... NJD002200048:. 2:1780t1�3iRST�STEiEETz;;-�.=, i F a Plnatp; :+ t ga. 9b.U.S.DOT Description(Including PrapetlSidpping Name,Hazard Class,ID Number, 10.conlekners 11.Total 12.Unit 13.Waste Codes HM and Pacl ing Gr-P Vany)) No. Type Quantity WWoI. i(YON MOT°REGULATED�STATE REGULATED©ILYDEBRIS`> (I 27`'>. MA01 I 0 DM trvP w 2' f� 3. 4. 14. ' H&dbV Inaucbm midAddrh'md Inkxnadon,..DM70'SO 81WS SFgm l 1)Profita#148008 ASSORBANTlSOIU0I5BEL FUEL! r 15. GfMERATOR-&*FF9t0R'13 CERTIFICATION:I hereby declare that the contends of this oorhsignrtnent are and accurately above by the proper shipping name,and are classified,packaged, marked and labeledlptacarded,and are in all respells in proper condition for transport a000rdirg to ationel aznd govemmerdal regulaBons.H export shipment and I am the Primary Exporter,Ira*that the conterta of this corps mnent oonlorm to the tam of the attached EPA t. I cer lily that the waste mhiunizetorn statement identified ln4P 9FR 26227(a)(d t am a large quantty (b)(di am quantty tar)is true. ero131) ted/Typed ww Month Day Year j"r ❑Import m U.S. ❑Export from Port of entryfext: Transporter signature(for exports only); Date leaving U.S.: I W 17.Tmnspo*Acknowledgment of ReO*Of MaWWS i Printed/Typed Name Signature Month Day Yeaz TranWoez 2 FrIntaffIVW Name Signature Day Year 18.Diso epancy Type 18a.Discrepancy Indication Space ❑ Quantity ❑Residue ❑Portia!Rejector Dull Rejection 1 I Manifest Reference Number. t 18b.Alternate facility(or Generator) U.S.EPA ID Number 1 V Fadlftlrs Phone: Month, Day Year w 1Be.Signature Alternate amity,(or Generator) 1 I 119.Hazardous Waste Report Management Method Codes(,.e.,codes for hazardous waste treatment,disposal,and reCON systems) 0 1 H141 .12. ( Oeafgnatad FaaMty Owner or Operator.Certification of receipt of hamrdous.materials covered by the mantleat exwpt as nd0d in[tam 188 artre SlgneWre Month Day ear EPA Form 87DO-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM t I