2021101405_State Report 21-055-10222 NC_20211014

PE5
11/2/2021
Subject: State Report for Incident No. 2021101405
PREMIUM
ENVIRONMENTAL
SERVICES
Please find enclosed the "Interim Release" for the incident in Mooresville, NC on October 14, 2021. Upon
review, please provide a "No Further Action" or equivalent letter for the above incident. If you have any
questions or need further information, please contact our office.
Sincerely,
Cindy Adams
Premium Environmental Services
812-853-2400
P.O. BOX 370 — Newburgh, IN 47629 — PHONE: [phone] — FAX: [phone]

WO4cc37a.1
GENERATOR - O.
NON -HAZARDOUS
WASTE MANIFEST
1. Generator ID Number
2. Page 1 of
3. Emergency Response Phone
L, _ 67c _.
4, Waste Tracking Number
5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
Ilf )1uMUHVIrun mo n-(- ' Acor e 111 L
Generator's Phone: I r1\tY 0 k- iv---; r
6. Transporter 1 Company Name U.S. EPA ID Number
CE l l i . «.. ..
7. Transporter 2 Company Name U.S. EPA ID Number
1
8. Designated
s(n
Facility's
�T.
Phone:
Facility Name
and Site Address
phr
U.S. EPA ID Number
(� nor 10� �t �L 2 � � c
Or to
9. Waste Shipping Name and Description
10. Containers
11, Total
12. Unit
No,
Type
Quantity
Wt.Nol.
0i1C) 1Walir
• .,
. .
3.
4.
13. Special Handling Instructions
and Additional Information
14, GENERATOR'SIOFFEROR'S
marked and labeled/placarded,
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,
and are In all respects in proper condition for transport according to applicable international and national governmental regulations.
Generator'slOfferor's
Printedrryped Name Signature Month Day Year
..
z
15. tntemational Shipments
❑ Import to U.S. El Export from U.S. Port of entry/exit'
Transporter Signature
(tor exports only): Date leaving U.S.:
TRANSPORTER
16. Transporter Acknowledgment
of Receipt of Materials
Transporter 1 PrintedfTyped
Name Signature . Month Day Year
Transporter 2 PrIntedrTyped
Name Signature • Month Day Year
t�--- DESIGNATED FACILITY
17. Discrepancy
17a. Discrepancy Indication
Space ❑ II Quantity Type ❑ Residue ❑ Partial Rejection Full Rejection
Manifest Reference Number:
17b, Alternate FacIllty
Facility's Phone:
(or Generator) U.S. EPA ID Number
17c. Signature of Alternate
Facility (or Generator)
Month Day ff Year
18. Designated Facility Owner or Operator: Certification of receipt of materials covered by the manifest except as noted In Item 17a
PdntediTypedName ry%�
V
Signature I Month
• _._..____ ____
Day I Year___..
.._.._
169-B LC-O 5 11977 (Rev. 9/09)

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