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NON-HAZARDOUS 1.Generator ID Number 2.Page—1of 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 - LAT - MAY 1 9 <br /> 5.Gear rs e n ailing A dr I Aft: LAUREN AKINS Generator's Site Address(if different than mailin address) <br /> 500 ��nhn�OMN FOEWIGHT LINE INC. OLD DOMINION FREIGHT LIME INC. <br /> 500 OLD DOMINION WAY <br /> THOMASVILLE NC 27360 601 DRRCY PARKWAYLATHROP CA 95330 <br /> Generator's Phone: 336 8225760 <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 ID Number <br /> q <br /> 8.De�lgpg�d�g011ty-IVa8e apd Sj�2ddress U.S.EPA ID Number <br /> C1630 WEST 1V7TtHK SVTIVREET <br /> LONG BEACH CA 90813 <br /> Facility's Phone: 800 827-6729 C 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 /> L d1C1fll 1 fe7GR►l(1(15 RTF Cnl Irl Gnnn rr r r_ No. Quantity Wt.Nol. <br /> Type <br /> ccO <br /> Lu <br /> 2. NON HAZARDOUS WASTE LIQUID-FOOD STUFF <br /> °`°2- kv P <br /> 3. _ <br /> ne REFUtEMM wAs1E WAS I WEVVW.11110 DLED AND STOM Fottss oFI-rs , <br /> 1)13POSAL.JMTMENT OR REUS&MOSBY t 0VMT01N.1 9C.OPERATES I IM FACM 11111ck <br /> PERMITS C RAMED TO THEM,BY TIS DEMAR OF TO C SUBSTANCE CONMOL7V RE7HEt <br /> 4. WM4 THE 9NV0tON AL <br /> THE RESOURCE CONSOWAT10N AND RECO Y ACT OF 1976 TOGUMIlt wrof IC1lBi!' <br /> FEDERAL AND STATE WMLA ONS. C 8456 ! 0 N HAS All OF THE SSAR� . <br /> rVRMM TO ACWT THE RM kkENNCMM WA AND AM THE WASTE HLAS ! NANdFP <br /> 13. Ha%�t do?1 AdI In#rmd�n <br /> 19-00194 (PETROCHEM PO H35903-19) 1) 108728 2) 108739 <br /> CA4452., CA4454, CA4456, CA4459, CA4509 <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,ancl ssified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> Generat s/Offeror's Printed/Typed Na Signature Month Day Year <br /> r <br /> 15.International Shipments <br /> Z ❑Import to U.S. ❑Export from . . o entry/exit: <br /> — Transporter Signature for exports only): Date Ieavin U.S.: <br /> r¢ 16.Transporter Acknowledgment of Receipt of Materials <br /> Transporter Y PTrinted/ryped Name (�'/ Signature / <br /> J ��'`U V ,/ /Month y Year <br /> O <br /> M <br /> a Tfaroorter 2 Plinte6Typed Name Signatur Month Day Yea <br /> °` Oy <br /> F- <br /> 1 iscrepa <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 17b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> u¢- Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a . <br /> z <br /> Lu <br /> 18.Designate Facility Owner or Operator:Certification of receipt of mate' Is covered by the manifest except as noted in Item 17a <br /> PrintedlTyped me Signature MonthDay e <br /> It\1 <br /> 169-BLC- 1 977(Rev.9/09) DESIGNATED FACILITY TO GENERATO <br />