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Pleas6-*trortype.(Form-designed for use on elite(U-pitch)typewriter.) Farm Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Nomber WASTE MANIFEST C A fir ❑ D o 4 2 4 8 1 7 1 8W 624-913$ 01,3897393 J J K 5,Generatots Name and Mailing Address . enerator's Site Address(if different than mailing address) OLD DOMINION FREIGHT LINE INC. Att:LAUREN�N�OLD DOMINION FREIGHT LINE INC. WO OLD DOMINION WAY 609 DARCY PARKWAY THOMAMLLE NC 273W iATHROP CA 95330 Generator's Phone: 6.Transporter 1 Company Hanle U.S.EPA ID Number Patriot Environmental Services C A ❑ ❑ 5 3 8 6 6 7 9 4 7.Transporter 2 Company e r -•�— r U.S.EPA ID Nu ber . G. Jr!`i5f C °•s?0r- roc, o��S2 % 8.Designated Facility Name and Site Address U.S.EPA ID Number CROSBY&OVERTON . 9830 WEST 17TH STREET LONG BEACH CA 90$13 Facility's Phone: 800 827_6729 C A 0 2 8 4 0 9 0 1 9 ga. 9b.U.S.DOT Descriplion(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WI.Nol. u SoLuTIONS, ,moi C� ��c. ��3 075-tu 2. NOW RCp�N ss AZA 9 DOU� WA 01DDoi o P:1 . 3• N O AZO D U3 V'J A VE NeNE SO L ID (OIL D p_15) ( ')I 1�0 . 4 14.s S Handlin instructions and Additional 1n rmat o IS.$:.PR�PER -RPfi:-.7QB (# -1-9--[]0 (PETROCH M PQ g.- 0 1.9CA 433 9, CA q 3 8 7/ C74 Lf-3 Ls S CA 43 2 L CA q3 0 3 , CA 0 v, CA Q q?,q, (1)Q f a Z. GENERATOR.'SIOFFEROR'S CERTIFICATION:i hereby declare that the contents of this consignment aro fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable International and.nallonal governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of thls oonsignment conform to the terms of the attached EPAAcknawledgment of Consent - e I certify that the waste minIrnixation statement identified in 40 CFR 262.27(x)(ifI am a large quantity generator)or(b)(KI am a small quantity generator)Is true. �:d 7 7ne,rata slOfferor Printedff d ae SigreMonth Da ear In. C r 16,international Shipments r ❑tmpod to U.S: ❑Export from .S. Port of entryfexit: Z Transporter signature(for exports only): Date leaving U.S.: w .Z7,.�TnspoderAcknowtedgment of Receipt of Materials Transporter PdntedIT Name Signature Month D Year Z Transporter 2 nted/Typed N Signature ! 1 / < f r g- Month Da Year I&Discrepancy f 18a.Discrepancy Indication Space ❑ Ouantity ❑Type ❑Resldue ❑Partial Rejection ❑Full Rejection b.Alternate FaG1i Manifest 18 f n ty[or Generator) `I IMSPOSAL.TREATIAEXt OR R�1 s CROSBY IR !IN YEh%P AIV@bCpEFr I•E8 nW PAC ZI UNDkA e Pp 'i 0kAt�tEb TO T MM.BY 7W DFPARTAffM bF JVXIC SUBSTANCE CONTROL.7�OWMEV. WaKTltE QIVOIONMMAL PROTECTION A CY IN ACCORDANLI WrM TFC tROVTSIONS OF FaraGtysPhone: RESOURCE CONSERVATION AND RECOJERY ACT OF 1976 TOGETHER IMM APPIACABIF LU 18c.Signature of Alternate Facility(or Generator) VUM@kAL AND STATE . LAWO Q rfkI.�ST'S TD ACCEPT THE RFkMENCED WASTE AND ZL"'ZnW WASTE � �Year- 19.Hazardous Waste Report Management Method Codas Q.e.,codes for hazardous waste treatment,disposal,and recycling systems) A i. 2. 3. 4. 20.Designated Facility Owner or Operator.Cert fication of receipt hazardous materials covered by the manifest except as noted in Item IBe PrntedlTy dN mem Signature Month Da Ye L 15 C � -----' EPA-Form {Rev.3 05) Previous editions are obsolete. DESIGNATED.FACILITY TO GENERAT R