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NONHAZARDOUS 1•Generator 1D Number 2.Page' <br /> of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generatfl>'s Site Address(11 differem than mailing address) <br /> Aft: LAURENAKfNS <br /> ' OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. <br /> 500 OLD DOMINION WAY 603 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> = Generator's Phone: 8225760 <br /> > ' <br /> r, <br /> 8.Transporter 1 Company ame U.S.EPA ID Number <br /> ! <br /> r <br /> 7.Transporter 2 Comparry Name U.S.EPA ID Number <br /> .r S c S r r 7-y [� <br /> rrn�r r r-s[ C-. 11-sa- �r�4En t... r�5'.��SZ ■ T <br /> 8.Designaled Facility Name and Site Address U.S.EPA ID Number <br /> CROSBY&OVERTON <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facili 's Phone: <br /> 10.Containers 11.Total 12.Unit' <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity WIJVol, <br /> 1. <br /> a . <br /> cc <br /> W <br /> Lu <br /> NON HAZARDOUS WASTE LIQUID-FOOD STUFF <br /> V fJ 2—'n } <br /> 3. <br /> FIF RFFERPN WASTE WAS RECFJV>D HANpLED A S11WTE FOR SUESlaQInSrT DFFSrT r. <br /> I7ISPOSAL,TREA OR RUL ;E CROSBY t OVERTON. NC.OPU ATES TUF FACMM UNU0 .. <br /> s'F3tA4Cf5 GRA 1'OT7{EM.H THE DEP T-61F.NTOF TO fC SSruS ANCE COINMOL 7DGT_T19:s <br /> '+V ENV ONMENTAL IGH GEN LY <br /> IN AC Y]rcr7NNE WFTII T][>;.PKO�'LSrr7N5+r <br /> 4. T}l RESOURCE NSERVATTG AND RE V1:XY ACT U 197r 'fL' IM3t wall f r'LICAK; <br /> FWMLkL AND ATE REGUL TIONS, 00SKY E OVENTON HAS ALL OF T)W, P+E[Tc:nk <br /> • <br /> 14w-mm TO A THE=CED VAM AND Al L T1iE ASTE HAS II" HA ND4 FJ <br /> 13.Special Handling Instructions and Additional Information <br /> USE PROPER PPE .70E # 03-•19-00194 (PETRGCHEM F0 H35780-19) 1)198729 2) 108739 <br /> I CA4302, CA4306, CA4307,CA4312, CA4313, CA4347, CA4378, CA4383, CA4384 L, <br /> 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of Ibis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlptacarded,and are in all respects in proper condition for transport according 10 a livable international and national governmental fegulations. <br /> Ge erator'sfOffercie rinledffype Name n Month Day Year <br /> AA_jQ (0 a <br /> j 1 .International Shipments <br /> ❑Import to U.S. ❑Export fr—qT.S. Port of ealrylexil: <br /> -- <br /> Transporter Signature for ex ods only): Date feavin U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Malerials <br /> Trans er 1Prinledrfypad Name Signatu Month Day Ye r <br /> QTransporter 2 Pr n edlTyped Na Signature a Month Day Year <br /> e� 17.Discrepancy ' <br /> 17a.Discrepancy Indication Space ❑ ' <br /> v. ❑Quantity ElType• ❑Residue ❑Partial Rejeclion Full Rejection <br /> a <br /> Manifest Reference Number: ezz <br /> 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> zi {L <br /> f U <br /> w Facility's Phone: <br /> 4 <br /> E= w 17c.Signature of Alternate Facility(or Generator) Month Day Year _ <br /> 1�7t O <br /> } 18.Designated Facifi Owner or Operator:Certification of receipt of maleriats covered by the manifest except as noted in item 17a <br /> r d <br /> 1 PrintedlTyped Name. Signature Month Fay Yea <br /> 169-SLC-0 5 11977(Rev.9109) —� ESIGNATE D FACILITY TO GENE ATO <br />