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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Numbar <br /> WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 13006249136 O D F L - LAT - JAN2 0 <br /> 5.Generator's Name and Mailing Address At_ LAU REN AKI NS Generator's Site Address(if different than mailing address) <br /> OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. <br /> 500 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95334 <br /> Generator's Phone: 336 82255760 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Patriot Environmental Services CAD 0 5 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> OS <br /> 8.Die graaledBt Fa iName and 15itOe dress U.S.EPA ID Number <br /> 163D WEST 17TH STREET <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 /> 10.Containers 11.Total 12.Unit <br /> 9.Waste Shipping Name and Description <br /> No. Type Quantity Wt.Nol. <br /> 'NON HAZARDOUS WASTE SOLID-FOOD STUFF-BREAD ®�� � � L�� �- <br /> o MAKING FAT,STARCH, BEEF BROTH, DRIED SUGAR, <br /> a MAYONNAISE, SALT, FLOUR <br /> w <br /> 2NON HAZARDOUS WASTE LIQUID- FOOD STUFF 00 <br /> too f <br /> :lisliJShL,712fAT.lL:h-1'G7: r- �:_ �. - ,.: . -r- ::=t:S!E�k:•i i L a'Si1'k <br /> P}::RNMS GRAN—TM To;7,;;\: .. .'i a_ E.....J`.,, •Is.,l al':1=rY '�n„y <br /> =:rrlt n1Ekfiivntp>:..41:;f1'A!. ''..•..Nr� ;��.-l'.<D[..TY;('t _ , <br /> fILE RFSoLrRCE <br /> 4. 't: AND ST.41li ._.0 .,.,.•'i7ii;21',Vr71; <br /> 4'r"'l'I'S ZQ ACJTrr ilii: ,.. ., ... .... F .rt. <br /> 13.Special Handling Instructions and Additional Information <br /> �rS 'Rt��PER PFE J :P, rt :__h;_ •it r��,;, _t _',0729 2' . 1?'�'72r� <br /> Ix V—0 (-I)Q T-0 <br /> 14.GENERATOR'SIOFFEROH'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 according to cable international and national governmental regulations. <br /> r�tors101fef Printed ype Nam Sig ,f e Month Day Year <br /> I C 17 <br /> J 5.International Shipments11 <br /> Imperil to U.S. Export from Port of entryfexit: <br /> z Transporter Signature for ex orfs only): Date leaving U.S.: <br /> ac 16.Transporter Acknowledgment of Receipt of Male1als <br /> Lu <br /> c0cI- Transporter 1 Printedfryped Name Signature Month Day Year <br /> SIO i1 !7 ? <br /> a Transporter 2 Printedfryped Name Signature Month Day Year <br /> cc <br /> F <br /> 17.Discrepancy <br /> 17a.Discrepancy indication Space <br /> ❑Quantity El Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> k}- 17b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ua. Facility's Phone: <br /> w 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> cs <br /> B.Designated Facility Owner or Operator,Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printedfryped Name Signatur Month Day Year <br /> if. orrna <br /> 169-BLC-O 5 77(Rev.9109) DESIGNATED FACILITY TO GENEAATOA <br />