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C. <br /> Please print or type. <br /> Form Approved.OMB No.2050.0033 <br /> UNIFORM HAZARDOUS 1.Generator ID Humber 2.Page 1 of 3.Emergency Response Phone 4.Manifest}TrackinIf Number <br /> WASTE MANIFEST [ A L A © Q. -!��2481 7 J $Ila 624-9136 02035.1075 J J <br /> 5.Generator Mame and Malin 'Address Att:LALiEZi;iV•AIUI�I�kneratvr s SiteAddress(if diI[erent than mailing address} <br /> OLD DOMiNiO�i FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. <br /> 500 OLD DOMINION WAY 609 DARCY PARKWAY <br /> THOMASVILL.E INC 27360 LATHROP CA 95,330 <br /> Generator's Phone: 3 3 6 8 2 2 5 7 6 0 <br /> fi.Transporter 1 Company Name <br /> Patriot Environmental Services U.S.EPA 1D Number <br /> C A D r0 5 3 8 6 6 7 9 4 <br /> 7:Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facjiity dar6V <br /> nd Site Address �f. <br /> CRos�` $ RTQNU.SEPAIDNumber <br /> 3�WI<sFH srrt��T <br /> LUNG BEACH CA 90813 <br /> Facility's Phone: 800 827-6729 C A D 0 2 8 4 � � <br /> ga, 96.U.S.00 pescription(ncludlag Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group¢f any]] 11.Total 12.Unit 13.Waste Codes <br /> �. No: Type Quantity WLNoI. <br /> x 1.LI NIZ.0 5) Gti Vyl Y1� <br /> ro <br /> Is IF&M 00 t DF 1 J C) <br /> Irl <br /> W <br /> 2. S.S,t <br /> C7 <br /> 3. <br /> - s i <br /> t. <br /> 4. <br /> 14.Specie!Handling lnsrructions andAddilionallnfarmaGon # <br /> L15�;: JtUPi;R <br /> 15: GEHERA70R'SlOFFEROR'S CERTIFICATION: there declare that the contents of this consi mrnenl are fully and accurately described above by the <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable in lemational and national govemmenproper shipping name,and a d i5ged, <br /> laf regulations,if.exp nashipment and i am the Primary <br /> Exporter,l certify that The contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste'minimiza3ion statement identified!n 4R CFR 262.27[a]{if I am a large quantity generator}or(b){if I am a small quantity generator)is hue. <br /> General es1011eMrs Pint yped N me _ Sign <br /> h/'. Month Day Year <br /> 4ip L t.CL.- ►y <br /> _.r 1[i.Intemativnal Shipments w I v L � p+� <br /> ❑Import to U,S. <br /> Z Transporter signature IF—:--xports only}: ❑Export from U. Port of enhylexit: <br /> W 17 .TransporlerAcknawledgment of Receipt of Materials Dale leaving U.S,:- <br /> F- Transporter 1 PrinledlTyped Name <br /> V0 <br /> Transporter 2 Printedrryped Name <br /> S gnatu Month Day Year <br /> 18:Discrepancy <br /> 18a:Discrepancy Indication Space ❑•quantily ❑Type <br /> El Residue ❑Partial Rejection ❑Full Rejection <br /> 7� W ED-HANDLED AND STORIED <br /> ]8h.Allemate Facility(or Generator) I,ImjPOR SUBS LrEw <br /> ..1 1'CRMUS GRANTED To T1tBj.BY T.1113 I I I FACILITY UNDER <br /> L) VM1 THE ENWRONMENTAL SUBSTANCE OpHTRO(,�GETF� <br /> 11 PRDTEC7IGN AGENT y.IN ACCORDANCE WMI•THE PROVLSIOHS 4P yy <br /> Facility's Phone: - i'FDF O n VATTON AHD RE VERY.QCT OF 1976 TO rGSTIMR W <br /> UA18e,Signaluue of Alternate Facility f ar Generator}. REGUL A170HS, OSBY � DVERTON �APPL.ICABLF <br /> A AND.ALL TIL%WA <br /> • �nrNGCv NA�hBI <br /> 55 19.Hazardous Waste Report Management Method Cedes(i.e.,codes for hazardous waste treatment,disposal,and re <br /> LU <br /> i recycling systems] <br /> o 2. 3. A. <br /> 26.Designated Facility Umar or Operator.Certifcabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinledrTyped Na <br /> } Signature <br /> �.L Month Day Y ar <br /> 1 <br /> EPA Farm 870 - (R .12-17) Previous editions are obsolete. <br /> DESIG ATED FACILITY GF ERA ' R <br />