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Please print or.type.. Form-Approved.:OMB N6.,2050-0039 <br /> UNIFORM HAZARDOUS 1:Generatdr ID Number 2.Page 1 of. 3.Emergency Response Phoma 4,MaannNutt Tracking Numbersc /� /� <br /> WASTE MANIFEST.. - C»A..L .0,:-0 0 4 .2..4.::8 .1 ? 1 $00$24-9138s�p V L 03.5 V O:4`! 'JJ K <br /> 5.Q �IL�t 1lgggl� InI�EIC�MT LINE INC. 8[ t�s to f{VjeC]Nf FREfGPTaI'!I�1aE IIV�. <br /> 5W OLDDOMINIONWAY 661 DARCY PARKWAY <br /> THOMASVILLE NC 27360 'LATHROP CA 95330 <br /> Generator's Phone: 3 3 6 82 25 76 0 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> Poot Environmental Services - C A D 0 5 3 8 8 8-7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number .. <br /> 8.ti?CLJ�r3T�e.bv 16A?. <br /> dress_. Y U.S.SPA ID Numbef <br /> 1$30 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Fa ility's Phone:8 •-•8278729 1C A D..0 2 8 4 0 8 0 1 9 <br /> ga, 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantily Wt 1vol, <br /> 1UN3280,Corrosive solid,acidic,€rwrg@dc,n.o.s. g1 <br /> o X 8,PG€Ii <br /> 0.0:1 DP 00200 P <br /> w <br /> z 2 <br /> w <br /> TICE REFERENCED WASTE WAS.RPCEIVED.lfAK)LED.AND STORED R SUMFAU - .OM[Ti <br /> DISPOSAL 7$,MATM-Elrr.OR RR!SG.M.OSBY k OVERTOP,TI C:GPERA TttE FA UNDER <br /> GatANTw To-mEd,DY i etc�.i_:,s i4•"�•:z;?i t.0.^^•TG:i:C SLrDSTA.CO's CQMI'RO . <br /> 3t a FSiYRtGNr AL t LC`,::': :,t:': M�CCGP,F.',NCE 1 THE PPRQ [OHS OF �AIE <br /> THE RESQURC@ CGNSt�m-no '" iR•76 Til IFRR WrM ICABz> <br /> TEDF3tA1.'AND.STATE arE[UL:t';':. . :SPY i14a" QP TaIE SARY <br /> . .. •- . ..5'ERMITS�-1►C1�'�'F 713E P.Li- t. r,n:.L 7'119 WAS tIAS B>:8H hrnl4, <br /> 4. <br /> 1401 ct' �°d� " �aI fo`��on-•19-OQ365 (PETROCHEM PO H3658$-19). 1.}1,00554 <br /> � � <br /> _f� O NN, i\) �N Cb t--L_ - r4r <br /> >�1-7 <br /> 15.'GENERATOR'SIpFFEROR' CERTIFICATil7N: I hereby ifeClar,Iti,4t the Cornlents of Ihl�daiisfghmer are.(p�ly and Kt*ratelydescr bed above by the.proper,shipping namq ani are classified,plaaged, <br /> marked and labeledfplacarded,and are In all respects in proper eondi8on for transport aoebrding to applicable international and national go�emmentbl re4ulatlon§-If expolt shipment and ram lila Primary <br /> Exporter,l certify that the contents of this consignment conform to.the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.21(a)(if I am a large quantity generator)or(b)(if I am a sma11 quantity generator)is true. <br /> Generator'slageror's Printedffyped Name Signature Month Day Year <br /> _j 16.International Shipments <br /> ❑Import to U.S. ❑Exportfrom U.S. Port of entrylexit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> � <br /> IT TransporterAclueMedgment of"t of Materials <br /> i i Transporter t Priritedfryped Ham S Signature Month Day Year <br /> a <br /> NE Transporler.2 Prinledffyped NameSignature Month Day Year <br /> 18.Discrepancy 2. <br /> 18a,Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejectidn ❑Full Rejeclion <br /> Manifest Reference Number. <br /> 18b.Allemale Facltily(or Generator) U.S.EPA ID Number <br /> U <br /> tQL Facility's Phone::... <br /> LO 18c.Signature of Alternate Facility(of Generator) -..-..... Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(0,,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. [, 2. 3, 4. <br /> 2G.Designated'Facility Owner or Operator,Certification of receipt of hazardous materials covered by the manifest enepl as noted in Item 1B <br /> Pr n(edff Name Signalure Month Day Year <br /> EPA Farm 8700-2 ev.12=i7) Prevlaus editions are obsolete. DESIGNATEII FACILITY TO GENERATOR- <br />