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NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address enwalors Site Address¢f different than mailing address) <br /> OLD DOMINION FREIGHT LINE INC. LAUREN OLD DOMINION FREIGHT LINE INC. <br /> 500 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASMLLE NC 27360 LATHROP CA 95330 <br /> Generator's Phone: <br /> 6.Transporter 1 Company Hame U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S,EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA l❑Number <br /> CROSBY 8r OVERTON <br /> 1630 WEST 97TH STREET <br /> LONG BEACH CA 90813 <br /> Facili s Phone: <br /> 9.Waste Shipping Name and Description 10.Containers 11.Total 12,Unit <br /> No. Type Quantity wuvol. <br /> sx NON HAZARDOUS WASTE SOLID—FOOD STUFF <br /> t7D� DF �� <br /> rc .. <br /> LLI . <br /> Z <br /> 2' NON HAZARDOUS WASTE LIQUID-FOOD STAFF r <br /> 4. <br /> 13.Special Handling Instructions and Addirionaf Information <br /> USE PROPER PPE JOB # 08-19-00265 tPETROCHEM PO H •-34.1.`M —19) 1)108728 <br /> 2}108739 <br /> CA151 i CM 006 CM4,N ) <br /> 14.GEN ERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of ihi WASwadQsilore classified,packaged, <br /> marked and tabeledlplacarded,and are in ail respects in proper condition for transport according to applicable intemalional and national governmental regulations. <br /> Genratoeswerors P'ted+Typed Name�C(&nac Y_ . g lure �j p Month Day tY r <br /> i <br /> j ntematianal Shipments <br /> Import to U.S. ❑Export fro U.S. Port of entiylexit: <br /> Transporter Signature for exports on : Date leaving U.S.: <br /> cc 16.Transporter Acknowledgment.of Receipt of Materials <br /> LLSTransporter 1 PrintedlTyped Name 5ignatur h�lh fly IT <br /> N `TJ <br /> Q Transporter 2 Frinted/Typed N Signatur Month Day <br /> 17.Discrepancy <br /> 17a.D saepancy Indication Space - ❑Quantity ❑Type ❑Residue <br /> ❑Partial Rejection El Full Rejection <br /> Manifest Referenoe Number: <br /> 17b.Alternate Facility(or Generator) I U.S.EPA ID Number <br /> _i -9lE REVERJENCED WASTE WAS RECEIVED,HANDLED AND STORED FOR 5UUSNUpMT OFKr11 <br /> DISPOSAL-TREATMENT OR REUSE_CROSBY A OVfRTON.INC,OPERATES M FACUy'[y UNpEP <br /> LL Facility's Phone: I'FRXM GRANTED 76 THEM.BY TIBC'❑EPARTFTN T OF TO?I UDSPANCE coN'moL,TQGEftff. <br /> m 17c.Signature of Alternate Facility(or Generator) DIP RESOURCE CONSERVATION AND RECOVERY ACT OF 1976 TOG M. JER WrM APPLICA ri Doth Day Year <br /> N l•TDERAL AND STA itEGULA71Oti5, CROSBY &. OVFRTt7N HAS ALL OF VENECESS 1 <br /> Z e <br /> 777,N <br /> fZ <br /> 18.Designated Facility Owner a ralm:Certification of r2ceipt of m lerials covered by the manifest except as rioted in Item 17a <br /> P6nledlryped Name C_ Slgnature Month ❑ ea <br /> 17111 <br /> 169-BLC-0 5 977 CRe .9109) DESIGNATED FACILITY TO GENERATOR <br />