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NON-HAZARDOUS 1 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Nvmber <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> OLD DOMINION FREIGHT LINE INC. Aft LAUREN AI(!NS OLD DOMINION FREIGHT LINE INC. <br /> WOO OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 96330 <br /> Generator's Phone: n12 8225760 <br /> 6.Transporter Y Company ame U.S.EPA ID Number <br /> 7.Transporter 2 Company Nam _[[ U.S.EIQ Number <br /> r�� �-� PA or���z Z7 If <br /> 8.Designated Facility Name and Site Address U.S.EPA IQ Number <br /> CROSBY a OVERTON <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facili s Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11,Total 12.Unit <br /> No. Type Quantity WtNol. <br /> 0 1 FOOD STUFF-JALAPENOS/PRODUCTSISEA SALTINUTRIENT <br /> a DRINKS/VITAMIN CBIRD FOODICOCONUT FLAKESICORND- 00� <br /> ,r <br /> 2.�41� �kA' J�IbC3 LAS LI I hq5 out I] <br /> C� oiz 002, <br /> FOR SUBSE <br /> WAS RF.CFI Fl].HAND AND'�O TES 71{S:F CUM �� . . <br /> 'rrffi REVERE NCVD WAS•tE, SHY do DV Fat Ott.INC.0 F3[A OL.TQG <br /> l]iSPdSAL.'1RLA'NIL•Y:"OA RESiSt< 'TF¢.rC F TOXIC S HSTANCE CO <br /> •I1R:M.aY ill :Aft ACCORD, <br /> NCS W[1l-t ll pROVi51 1i5.Of:` <br /> APFLTH <br /> 4' 1EjUM ENV W I'11i TILE L7� RECOVERY OV17t1'ON ALL Of <br /> . <br /> . Ttm REsOURM CONSir3tVAT1ON A WAM MS OE EN i' .. ..... <br /> TW A}. AND SCATS REGUTA'S SON WAYMM D ALL . . <br /> TU-ICO'THE Rix <br /> 13.Special Handling lastruclions and Additional Information ■-- ORDING <br /> USE PROPER PPE JOB # 08-19-00111 (PETROCHEM PO H35566-19) 1)108728 CA4111, CA4137, <br /> CA4142, -CA4172, CA4169, CA4247, CA4273 ! Cd}�I <br /> X30 3V <br /> 14.GEN ERATOR'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, <br /> marked and label0placarded,and are In all respects in proper condltion for transport according to applicable international and national governmental regulations. <br /> ef Cf <br /> GeperalorsfOf{ero�sdnfedlT d ame n re Manch pay Year <br /> Ak_Lm <br /> -s 15.1ntemational Shipments <br /> w ❑imporl to U.S. ❑Export from PS. Part of entrylexit: <br /> z <br /> Transporter S•nature for ex orts only): Date leavin U.S.: <br /> w 16.Transporter Ackriowledgment of Receipt of Materials <br /> Transporter 1 Printedffyped Name Signatu Month Day Y r <br /> n �� . J` <br /> 0. � 2-2— <br /> z <br /> � i <br /> 4 Transporter 2 Pri`ntedlfyped me Signature Month Day Year <br /> � 17.Discrepancy` <br /> 17a.Discrepancy Indicat on Space ❑Quantity ❑Typo ❑Residue ❑Partial Relection ❑Full Relection <br /> Manifest Reference Number. <br /> 17b.Allemale Fad%y(or Generator) U.S.EPA-ID Number <br /> ..r <br /> ci <br /> ua. Facility's Phone: <br /> Lu 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z <br /> N <br /> vJ <br /> 0 <br /> �. <br /> 18.Designated Facility Owner or pperalor.Certification of recelpt of materials covered by the manifest except as noted in item 17a <br /> Prnt Name Signature Month Day Year <br /> X11LEV OF <br /> 169-BLC-q,5-"l 1,97-7 Rev.9/0 9) DESIGNATED FACILITY TO GENERATOR <br />