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NON-HAZARE}OU5 1.Generator Id Number <br /> WASTE MANIFEST C A L 0 0 0 4 2 .4 8 2.Page 1 of 3.Emergency Response Phone <br /> � 7 ,� 4.Waste Tracking Number. <br /> 5.Generators Name and Mailin Address 8006249136 O D F L - LAT - J U N 19 <br /> OLD DOMINI FREIGHT FREIGHT LINE INC. Att'LAUREN+4KINSGenerators Site Address{if different Ihan rrrailing address} <br /> 500 OLD DOMINION WAY OLD DOMINION FREIGHT LIN>=INC. <br /> THOMASVILLE NC 27360 601 DARCY PARKWAY <br /> Generators Phone: 336 8225760 L.ATHROP CA 95330 <br /> B.Transporter 1 Company Name <br /> Patriot Environmental Services U.S.EPA ID Number <br /> 7.Transporter 2 Company Name C A D 0 5 3 8 6 6 7 9 4 <br /> r1� 6 rte at��t��1 U.S.EPA ID Number <br /> 8.DeS819�S�Y AIaL]V�FtTU ss <br /> 1630 WEST 17TH STREET U.S.EPA ID Number <br /> LONG BEACH CA 90813 <br /> Facili 's Phone: 800 827_6729 <br /> 9,Waste 5hi fn Name and Description C A D 0 .2 8 4 0 9 0 1 9 <br /> pP g 10.Containers <br /> 11.Total 12,Unit <br /> 0 1 NON HAZARDOUS WASTE SOLID-FOODSTUFF NO. Type Quantity Wt-NOI. <br /> uj <br /> ( DM w z NON HA ARDOUS WASTE LIQUID-FOOD STUFF P <br /> c� <br /> C)bS D� ' <br /> -) <br /> 4. o <br /> US <br /> Y�K[7p1�;1{°n�E ddJ V�InfpJrrla}io��1 s_o o p� _ <br /> "UU CEOB 3 r�37F 3U 1 ] [ 'ETROCHEM PO Ii 3 g- —19) 1)10 6728 <br /> 14.GENERA7oR'SlOFFEFIOR'S C770 <br /> nd are C all res <br /> l fwrehy declare thal the contents of Ihfs consignment are fully and aocuralely described above by the proper shipping name,and are class fed,packaged, <br /> Marked and laboiedlplacarded,Ondare in respects in proper condition for transport according to a <br /> G era[orslOffero Printe yp d N a 9 ppiicabla International and national overnmental reguiatlons. <br /> Ii nalure a <br /> � .1 amational.5hipments j Month Day Year•: <br /> r ❑Import to U.S. <br /> Trans er Si nature fora rts an Export from S. Port of entry/exit• <br /> cc 1&.PransporterAcknowledgment of Receipt of Materials Date leavin U.S.: <br /> L Transporter 1 ant ed Name <br /> a Sfgnatu <br /> ZU) �1 Y r <br /> Transporter 2 Printedrryped Name Il <br /> PE Signatu <br /> 17,Discrepancy <br /> Month Day Year <br /> 17a,Discrepancy IndicaGan Space <br /> ❑Quantity ❑T e _:•.,"..,� <br /> ❑Partial Rejection• t ❑Full Rejection <br /> 17b.Alternate Facility(or Generalor) <br /> ftante Number. <br /> rulsposnaaT)rt xr vft <br /> I is�Nl r}ry 7}tr_� sE{[xvu�nY&OVlz nz N.l c v i7N6mbepsp <br /> iL'ilri.-nfE Er�rVlft0H O-11� FATES 71rg PAL• -rr O}l'.Sfl} <br /> t Facililys Phone: F�aTaacrlar,ACES GF raxrc suusrANt7 cbtinty u>ti <br /> i 17C.Signalure of Allemate f acility{or Generator) � � �CONSi7[v t711pti A. r"C6;F�YrTS AW r CaPErA ICE�'lTl4 71iE pRpyu o t flr <br /> 3 .a�unn _YC71[L'ki-Alr. [a C5 QSRY n �v :rvrr "uP. 'nu? Y <br /> _ Da Year <br /> i wu. As <br /> r NrAyr <br /> 1B.Deslgnaled Fac lily Owner or operator.Cerfirfcat on of receipt of materials covered by the manifest except as noted in Item 17a <br /> Prinledfryped <br /> e!57/[L Slgnatu <br /> r� Month pay Year <br /> -BLC-0 977(Rev.9109) J.3 J <br /> DESIGNATED FACILITY TO GENERATOR <br />