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Please print or type. Form Approved.OM Na.2050-0{139 UNIFORM HAZARDOUS 1,Generator 10 Number 2.Page I of 3.Emergency Response Phone 4.Manifest Trackfng Number �( WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 800 624-9136 5[ 020351266 JJ'■ s OLDtDOMINtONImFREIGHT LINE INC. f DLR D M NIDN�FREIGHT LNE INg�- 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMASVILLE NC 27360 LATHROP CA 95330 Generators Phone: 8 3 5 8 2 2 5 7 6 0 6.Transporter 1 Company Name U.S.EPA ID Number Patriot Environmental Services C A D 0 5 3 8 6 6 7 9 4 7.Transporter 2 Company Name U-S.EPA ID Number t3ZOted.FapHr�d 80'ress U.S.EPA ID Number 1630 WEST 17TH STREET LONG BEACH CA 90813 Facility's Phone: 800 827-6729 IC A 0 2 8 4 0 9 0 1 9 ga. 9b-U-S.DOT Description(including Proper shipping Name,Hazard Gass,ID Number, 10.Conlahers 11.Total 12.Unit 13.Waste Codes HM and Packing GtWP(rf any)) No. Type Quantity ffljvd, 001 �D 060 b qV I D CE" PAS F S0LiD [PA PAtV- om T)i20 P 4. lar]s air l i n dna natMV-20-100004 P'_TR"CHEI 09 H4724@-20 CA5398, CA5400, Cp5411 Dy szv 16- oy(IP30) -04 L, yv) 15. GEN ERATOR'SIOFFEROR's CERTIFICATION: I hereby declare that the contents of this consignment are fulty and accurately described above by the proper shipping name,are are classified,packaged, marked and iabeledlplacarded,and are in alI respects in proper cordition for transport according to applicable international and national governmental regulations.It export shipment and I am the Primary Exporter,I certify that the oontents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 GFR 262,27(a)(if t am a large quantity enerat r)or(by V1 am a small quantify generator)is true- Ge eratoeslOffe rinteV are 5 at Month Day Year SAAZ wicmW-t 2-o intema5mal Shipments ❑[.port to U.S. ❑Export trcxn POO of entry!exit: z Transporter signature(for exports only): Date leaving U.S.: W 11.Transporter AcknowledgmBnt of Reoeipt of Materials LLI Transporter 1 Pcintagryped Name ` Signature Month Day Year a aTs Transporter 2 PnMedfryped Name SipaturV Month Day Year e 1- 18.Discrepancy 18a.Discrepancy Indication Space ❑ ❑Partial Re ❑Full Rejection Quantity Type Residue lection j Manifest Reference Number: 18b-Alternate Facility(or Generator) U-S.EPA ID Number L] Z6 Facility's Phone: � 18c.Signature of Alternate Facility(or Generator) Month flay Year Q N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatrnert,disposal,and recycling systems) 0 1- 2. 3. 4. 20.Designated Facility Owner or Operator.Cerlitication of receipt of hazardous materials covered by the manifest except as nded in Item t Ba PdntedlTyped Name Signature Month Day Year EPA Form 870(1-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM!