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NO"AURDOUS 1•Generalor ID Number 2-Page 1 of 3.Emergency Response Phone 4.Waste TmAing Number <br /> WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 18405249136 O D F L - LAT - SEP 1 9 <br /> 5,Generators Name and Mail' Address Att: LAUREN AKINS Generator's Sile Address(it ri fferanl mailing address) <br /> OLD DOMINION7REIGHT UNE INC. OLD DOMINION FREIGHT LINE INC, <br /> 508 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generator`s 1 one: 335 8225760 <br /> 6.Transporter 1 Comparry Name U.S.EPA 1D Number <br /> Patriot Environmental Services C A D 0 5 3 8 6 6 7 9 4 <br /> 7,Transporter 2 Gomparry Name U-S.EPA ID Number <br /> 8.D gggVj N�mg Trtg AQdress U.S.FPA ID Number <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facie 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 /> S.Waste Shippirxl Noma and Description No. Type Qua" WtNp1• <br /> I NON HAZARDOUS WASTE SOLID-FOOD STUFF-BREAD <br /> - MAKING FAT,STARCH,BEEF BROTH,DRIED SUGAR, <br /> Q MAYONNAISE,SALT,FLOUR <br /> w _ <br /> 2-NON HAZARDOUS WASTE LIQUID-FOOD STUFF DCF r � <br /> Ls `Tll s: <br /> 3���ozc�Y �� 1►�41�^ ��� D to 1 Dl'1'] �0 •� F <br /> +�r►ak►►� y 5 ,r � <br /> IF44C3'6 QVA DTi,CA 5►ASAY) D c�[ b m )O D <br /> 13. S P110�ER PE 0B #f 0$19 -00365 1) 108728 2) 108739 PETROCH M PO# H36588--19 <br /> LCA4767, CA4768,CA4823,CA4831,CA4840,CA4848,CA4873 <br /> 14.GENERATOWSOFFEROR'S CERTIFICATIGN:I hereby declare That the oont"ol this consignment are fuAy and accurat*deschbed ahoy by the proper shipping name,and are dassrfied,}lackaged, <br /> marked and labeledlplacarded,and are In all respects In proper condition for transport acoording to apprrrable hvwnational and naSDnal govemr LOmat regulaffons. <br /> Generat sfOtferoes Printed+Typed Name Signa Month Day <br /> Year <br /> r L e 1� <br /> 15.International Shipments ❑irrrpod To U.S. ❑Expert!tom U. . Po a rylexlt: <br /> Tran er S' re for a Da I U.S <br /> m 16,Transporter Ackm*iedgmeM of Receipt of Materials <br /> Transporter 1 Pdnkd+Typed Name Signatu fd lDay Y r <br /> 0 li <br /> z Transporter 2 Printe&Typed NamSlgnatu Month Day Year <br /> 17.D screparxy <br /> 17a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number, <br /> 17b-Aftemate Fadi ry(or Generator) U-S-EPA ID Number <br /> J <br /> u�. FaciWs Phone: <br /> u, 17c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> N <br /> m <br /> 0 <br /> q - _ <br /> 'Na <br /> IS.Designated Facility owner or Operator`Cerdficatfon of receipt of materials covered by the manifest except as rioted In Frear 17a <br /> PrintedlTyped Name Signature Month Day Year <br /> 169-BLG05 11977(Rev.9/09) MESIGNATED FACILITYTO GENERATOR <br />