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4 <br /> NON-HAZARDOUS1.Generator IO Number 2,Page 1 of 3.Emergency Response Phone 4.Waste Tracking N umber <br /> a <br /> wnsra;�1ANIFESr C A L q C] 0 4 2 4 8 1 7 1 18006249136 O❑ F L - L AT S E P 1 9 <br /> 5-Generatur s Name and Mailing Address Att: LAUREN AKI NS Generator's Site Address(if different than mailing address) ; <br /> OLD DOMINION FREIGHT LINE INC- OLD DOMINION FREIGHT'1_fNE;NC. <br /> 504 OLD DOMINION WAY 601 DARCY PARK)NAY <br /> THOMASVILLE NC 27360 LATHRO P CA 95334 <br /> Genera[cr's Phone: 336 8225760 1 <br /> 6,Transporter 1 Company Name U.S.EPA t0 Number <br /> Patriot Environmental Services C A D 0 5 8 6 6 7 9 4 <br /> 7,Transporter 2 Company Name U.S.EPA tD Number <br /> S D[.siz�SBYI9 QVEKTC1Address U.S.EPA ID Number s .F <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facility's Phone: $00 327-6729 C A O 2 8 4 0 9 .0 1 9 <br /> 10.Conlainars 11.Total 12.Unit <br /> 9,Waste Shipping Name and Description <br /> No Type Quantity WINo1. <br /> NOM HAZARDOUS WASTE SOLID-FOOD STUFF- BREAD <br /> o MAKING FAT,STARCH, BEEF BROTH, DRIED SUGAR, <br /> a C3L�1 D <br /> s w MAYONNAISE,SALT, FLOUR <br /> w 2NON-HAZARDOUS WASTE LIQUID-FOOD STUFF <br /> f, <br /> I .S�v lr+a`r3•t�� �s�-lin <br /> ''t a ►J 4=lwC <br /> 13.S ectal Ha lin Instructions a Addwon Information <br /> CPL" FR ER 1=FL .FC.-,i k 0S 1 6 ii1 )877',a _ i:J "s T1P7—r :-_E:r.I <br /> 'A[ �l r'I r�=��1 r]a C I'1. r".l :� 7 r •�i+}Y^ <br /> 71 C� <br /> rllE RFlF1tFltiC 171Yt5TE L:'.4S P'?t7:r•,'r)-IL:tiT][CU nt;D STQICFD FSR SU$SE <br /> AL 7RPATSLC:T nrr rt:.. r r: , ttuier,rr+ars sn r. <br /> PER1N1T5 CR.ai� )�Ti r tir.I'•. - •, C -UES T7 fE PArustY UNDFR <br /> 14.GEN ERATOR'S10FFEROR'S CERVIQMltFtltiUftMrdeda.rRdl}94 the contents of this consignmeni are'fplty and a'&UFhiRWef.'4c f wv1bM kN the proper shipping name,and are classified,packaged, <br /> lacarded,and ai�1aRAo�s ' <br /> marked and Iabetedf w <br /> p pads $�0f7et:CiG7rlibon for transport according to applicable intemativrr`aFa'�id'rie'-[�F7�1•�OaFRum9vtal regulations. <br /> I`< Generalo sfOfferor'sPrinted/TypedName ,rv SignaMonth Day Yeart�� <br /> 4k ft <br /> fig'%; _j 15-fntemational Shipments <br /> F- ❑import to U-S. ❑Export from U. Pv of a Iry axil: <br /> ' r' <br /> — <br /> Transporter Si nature for exports only) Dal Ife in U.S.: <br /> z`" ¢ 16.Transporter Acknowledgment of Receipt of Materials ` <br /> [' w <br /> r.k Transpaner 1 Printedfryped Name Signalur -6g, M h Day �Y <br /> r . o � i &P, <br /> a Transponer2 Prinledfiyped Nam Signalur <br /> Month Day Year I 'i <br /> cc <br /> r�{1 <br /> IT Discrepancy <br /> 17a.Discrepancy Indication Space <br /> C _ ❑ anlily ❑Residue ❑Partial Rerjeclion <br /> El Full Rejection <br /> I• 1� .���+itlt E�.��fz t `i�C C tr;LTypeLei �t'�[�� I'� _ j <br /> Manifest Reference Number- ;, <br /> 176.Alternate Facility(or Generator) U.S.EPA 10 Number <br /> _j <br /> a i <br /> w Facili[y's Phone: <br /> 17c.Si nature of Alternate Facility arGenerator <br /> w g y f J Month Day Year <br /> � <br /> w I <br /> z <br /> 18.Designated Faplity Owner or Qpvralor:C rtifiCalion of receipt of materials covered by[he manifest except as noted in Item 17a <br /> PrintedlTyped Name Martin Day Year <br /> zV <br /> i69-BLC-Q 5_ 77(Rev.9/0 9) DESIGNATED FACILITY TD GENERATOR <br />