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`Please print ortype.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050 0039 UNIFORIN HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking NNumber t WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 S0.624—S13S w f rtilA 5.Generator's Name and Mailing Address A LAUREN AINSGenerator's Site Address(if different than mailing address) OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. 500 OLD DOMINION'WAY 601 DARCY PARKWAY THOMASVILLE NC 27360 LATH CA 95330 Generators Phone: 2 6.Transporter 1 Company Name U.S.EPA ID Number Patriot Environmental Services ; 'A D 0 5 J0. BBB 7 9 7.Tra sporter 2 Company Name + U.S.EPA ID Number Tcresignated Facility Name and Site Address U.S.EPA ID Number CROSBY&OVERTON 1630 WEST 17TH STREET LONG BEACH CA 90813 Facility's Phone: ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 4 HM and Packing Group(if any)) r 11.Total 12.Unit 13.Waste Codes �n I�� T'� No. Type Quantity Wt./Vol. rflA '51 PLO- > ,� CC -,3 PlyC� D01 -DF )5ci s- )II --F—"-'- UJ— �! - cWO LID AAI2 P rm t t Villi'(? F L N -0, ,` p 14:Special" aridling Instructions and Additional Information � k�.. �� 1 . E - USP,-PROPER ,PPE JOB 0e—' —nc�}�a r ,e. (PETRp(!-HMA- 3590 !-H M x =is) , 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I herebydeclare that the contents of this consignmentare fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledlpiacarded,and are in all respects in properconditionfortcansport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statemenf'idehtified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I:am a small quantity generator)is true. Generator fferors Printed/Typed Name Signatu a Month Day Year y 3 j —J 76.International Shipments . ❑Import to U.S. ❑Export from U.S P o e try/exit: z Transporter signature(for exports only): D to le ing U.S.: LM 17.Tra hsporterAckiiowledgment'of Receipt of Materials 1�— Transporter 1 Printed(ryped Name Signature 0 } f� a , ! /J Month Dalyy . Year j� 1 rI r d .• `'1 @'4(d'�j 1}6� _ af�w.�� v�,.:� o°' i f a Transp rt r 2 PrintedlTyped Name J 1 a1 4!F Signatur Month Day_ Year 18.Discrepancy/` d 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re1jection ❑Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: FOR PJ16kasm w0le WAS VJX%1VPL,NANDUOs AND vIW4l • V mspe AL.4MAT&SNf OR MSE.C1t031y!OVtmI N.INC-OPWAIMS THE p'ACAIIV UKM u< Facility's Phone: 16RMM(*ANfW`T6 7flgM,fY TSS DFPa RTMEW OP TOXIC"STANCE COWM01„TOO "Ep IrONYAL MROIIj�'1'ION AMV H1 A MANCE WITH TI}E mavASIoms of L 18c.Signature of Alternate Facility(or Generator) no*001M fl CON56tVA'n N AM POP a ;,M)OL.,L, AND STATL' RECIU AMONS. CROSIIY !OVE111"M NAS.ALL OF T11! Sllltith Day Year Z TO AC'CPl't'TILE k#1*VEWVD W WM ANO ALL TIE MASI'fl;NAS SM..N "A w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous Ma"b'1��E1tfIIel(t,disposal,and recycling systems) G 1 e 2; 9t 3. 20.De"gnated Facili Owner or Operator:Certification of receip of hazardous materials covered by the manifest except as noted in Item 18a . Pdgt ype Nam Signature f I' /` I `� r M Day Year L EPA Fofrr( 760 22(Rev.3-05) Previous editions are obs lete. r "- DESIGNATED FACILITY TO GENERAT