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Y NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> ' WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 18006249136 O D F L - L AT - MAY 20 <br /> Via! <br /> ca 5.Generator's Name and Mailing Address Att: LAUREN AKINS Generator's Slte Address{if different than mailing address) <br /> OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINT=INC. <br /> 500 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generator's Phone: 336 822576() <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Patriot Environmental Services IC A D 0 5 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6,Desi nated Facility Name and Site Address U.S.EPA ID Number <br /> CROSBY&OVERTON <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facilit's Phone: 800 827-6729 IC A D 0 2 8 4 0 9 0 1 9 <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12.Unit <br /> No. Type Quantity Wt./Vol. <br /> 'NON HAZARDOUS WASTE SOLID-FOOD STUFF BREAD <br /> o MAKING FAT,STARCH, BEEF BROTH, DRIED SUGAR, <br /> 2-00 <br /> W MAYONNAISE,SALT, FLOUR I <br /> 2NON HAZARDOUS WASTE LIQUID-FOOD STUFF <br /> TIM"'l NCS WASTE WAS062— PF too P <br /> )[SPOSAL 7REA7'h1ER RE.Ct FLED,}CaNOI i <br /> ENT$S <br /> 3_ VIRO 7b 7}IFl f.SY 731£P]F�PARTh ETON,INC.OP ,47FS 71-1E PA O SE <br /> TJE �0IIVVIROTI3fi-h'1'AL PRGrECf[t)N q OF TUX[C SUBSTANCE CO UNDER <br /> ED RF,SOURCP CONSL•RVAT}ok A„7) GE.YCY )N ACCORDANCE NIR TOCE7?IER <br /> i�.13E![gP, ANO STATE REG[:4ATIUNS, OVfiAY ACT ) �}77� VISIONS OF <br /> pqs (P I976 TDG <br /> 4. ![2bCVq,y LNCET3 y'AST};:AND Aly 71� S ALL OF 7H!? NE�SARY <br /> BLE <br /> WASTE PIAS BEE IHANg1FD <br /> 13.Special Handlingg�Instructions and Additional Information <br /> USE PROM PPE JOB # 08-20-00249 1) 108728 2) 108739 PETROCHEM PO# 2027,01341-21-101392 <br /> CA5736,CA5 748,CA5843, CA5857 <br /> 14.GENERATOR'SlOFFEROR'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 labeled/placarded,and are in all respects in proper condition for transport accor" licahl international and national governmental regulations. <br /> G neralor's; r Prints y edNae �� � Sig u 5 � MDonth Day Year <br /> _r 15.International Shipmentsy1, 1�r511 <br /> M ❑Import to U.S. ❑Export from U. . Port of entry/exit: <br /> Transporter Signature lfor exports only): Date IeaVri U.S.: <br /> m 16.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> cc <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 V12- a U <br /> a Transporter 2 PrintedlTyped Name Signature Month Da Year <br /> cc <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space ❑Residue ❑Full Rejection <br /> ❑Quantity El Type ❑Pallial Rejection j <br /> Manifest Reference Number: <br /> F 17b.Alternate Facility(or Generator) U.S.EPA 1D Number <br /> a <br /> U <br /> rat Facility's Phone: <br /> LU 17c.Signature of Alternate Faci lly(or Generator) Month Day Year <br /> a <br /> z <br /> o <br /> 1 e.Designate Fa ility Own or Operator:Certification c receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed yped a Signature �� Mon}h Y <br /> IT <br /> 1 <br /> G <br /> 169-BLC-0 5 977(Rev.9109) DESIGNATED FACILITY TO GENERATOR <br />