Laserfiche WebLink
Please print or 4W.(Farm designed for use on elite(12-pitch)typewriter.) FormApproved.OMB No.2U5OM39 <br /> A UNIFOW!'AZAARDOUS 1.Generator ID Number 2.page 1 of 3.Emergeriey. Response Phone =0897393 <br /> cking Number �I <br /> WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 844 524-9136 J J K <br /> 5.Generators Name and MaTiing Address Att LAUREN AWNeenerabes Site Address(f different than malting address) <br /> OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. <br /> 6a4 OLD DOMINION WAY fiat DARCY PARKWAY <br /> THOMASVILLE NC 27364 LATHROP CA 95330 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Patriot Environmental Services C A D 0 5 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA tD Number <br /> S.Designated Facility Name and SBeAddress U.S.EPA ID Number <br /> CROSBY&OVERTON <br /> 1634 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facrit Ptwne: C A d 0 2 8 4 0 9 0 1 9 <br /> 9a. 9b.U.S.DOT Description(nduc$V Proper Shipping Name,Hazard Gass,10 Number, 10.Ctmtafners 1,.Tula! Q.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No, Tye Quantity Wi1Vd. <br /> ON 11 Wk�7V Ry ry UYLD X027 <br /> PA<--,:- 1001 DM 0-15- Ss <br /> C W D F <br /> 3. {} <br /> V1V 1+0"0 0—� A&1F II <br /> 50 <br /> 4. <br /> 14.5� Handling Instructions and Additional Information f1 <br /> [)5E PROPER PPE JOB # 08--19--00 l q 4 (PETROCHEM PO H 3Y7�—19) 5 � � a r"ID <br /> CA 433 9- CSA-43 $ (A 3 27 2,6 (A (430-3 , CAY410, CA u zq, � 1 � <br /> 15. GENERATOR'SH)FFEROR'S CERTIFICATION:thereby declare,that the contents of this cnnsgnmeM ara fully and acwrelelydescn'bed above by the proper shipping name,and are dam!W,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for bars p, according to apprrsable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify Mat the contents of this consignment conform to the corms of the atlached EPAAcknrnv38dgnteni of Consent. <br /> t tort fy Ihat the waste minknization statenwnt WoKod in 40 CFR 26227(a)(if I am a large quantity generator)or(b)fsFl am a small quantity generator)is true, <br /> toe sfORertxrprintedfTyT 3 Month pay Year <br /> PAMI <br /> III UAIOLL' <br /> o a I <br /> FJ . ntemationatShipments <br /> - ❑Impott to U.S. ❑Export fr .S. Port 61 entrylexii: <br /> Transporter. signature(for experts only): Date leaving U.S.: <br /> 17.TransporlerAdmowledgment of Receipt of Materlats <br /> LU <br /> a Transporter 1 Printed/Typed Name l Signature M6nth Da Year <br /> aTransporter 2 printedfTypod Name Signature Month Day Year <br /> tY <br /> t— <br /> I B.Discrepancy <br /> I Be.Discrepancy Ind calico Space ❑ Quantity ❑Type ❑Resekre ❑Partial Rei d. ❑Full Rejection <br /> MaNtest Reference Number. <br /> sob.Memate Facility(or Generator) U.S.EPA ID Number <br /> ..r <br /> ra FadlVs phone: <br /> LU i Be.Signature otAttemate Facility(or Generator) Month Day Year <br /> a <br /> x <br /> V519.Hazardous Waslu Report Management Method Codes(I.e.,codes for hazardous waste treabrrent,dsposM,arid recycling systems) <br /> C3 9. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Cerg alion of recelpl of hazardous matsfWs covered by ff*manifest except as nded to Item 183 <br /> Pn rttedlryped Name s7atum Month Day Year <br /> EPA Form 97Q0-22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />