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v.. Pleas6 print or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No,205X039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page hof 3.Emergency Response Phone 4.Marl[fast Tracking Number WASTE MANIFEST C A tdq 8OQ 624-9'i 3& J J K 5.Generators Name and Mailing Address �f�_LAUREN A N Generators Site Address{f different than mailing address) QLD DOMINION FREIGHT LINE INC. OLD DGMINIDN FREIGHT LINE INC. 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMIASVILLE NC 2736 LATHROP CA 95331 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA iD Number Patriot En+irvfimmta#Smites T;TranSpo[ter 2 Company Name U.S.EPA Iv Humber 8,Designated Facility Name and Silo Address U.S.EPA ID Number CROSBY&OVERTON 1638 WEST 17TH STREP WNG'SEACH CA 9a13 Facililtls Phone: a 9a. 9b.U.S.DOT Description{inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Padding Group(ifany)) • No. Type Quantity WtNol. 2-o DDDR 3 ! w 2' NON R C RA �1A-ZADoUS ]n1 M,-VIE 3. NDN RC RA �W-N"o US In1m;T E 4. N* RCRA WARDOO,. • WJA E 102- DIM o l 14.Special Handling Instructions and Additional Information }. i7SE_:.PI?( P R P.n.Z--„OS. .. .P .Op_18-00490 (PETROCHEK-Po H34515 -10)'. 1()()S2-%' i)- . �o G7 T; n q Lf 560 0� �3, ��o r Q 157GENEATOR'SIOFFEROR'S CERTIFicATioN: I hs eby aedA that the contents of t5is consignment are fully and accurately de'srrifbedabovety the proper shipping name,and are dasslfied,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Cansent. I certily that the waste minimization statement identified in 40 GFR 262.27(a)(if I am a large quantity generator)or.(b)(if.i am a small quantity,generator)is true. GeneratorstoFrerors P-tedffyped Nam Signature r Month Day Year 1 t -j 16.international Shipments F ❑Import to U.S. ❑Export tram U.S. Port of entrylexit: s Transporter signature for exports only): Dale leaving U.S.: W 17.TransporterAcknowiedgment of Recelptof Materials Transporter i PrEntedlryped Name Signature Month Day Year IL I :m�0 0 Q Transporter 2 Printedlryped Name Sign re Month Day Year a F 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type 1:1 Residue El Partial Rejeoticn El Full Rejection 'ftie REFERk7aCF�.1 WA WAS REC•EIVFD.FlANDLED AND STORM FOR SUBSEQUENT 4Fl5fll ostReteBensa NBmbeeRTnH,[NC-OPERATES THE FACU-rTY UNDER i8h,Alternate Facility(or Generator) t,y TS GRANTED Tin Tt u,BY Ttn-D&^ARTMEN or rc{� fi {� KU LLK ...r 'NM4 THE FTrvuRoHMENTAL PROTEL-FIO i AGENCY:JN ACCORDANCE.WrII.{THE PROVfSIONS OF U IILE RESOURCE CONS ERVAl70N-AND RL�C61'�K1�hCr OP 1976':0CI_MER WFM APMICABLE L<LFaa7ilysPhone: tin£Rnr wN0 TTAlE u�culA;wNs, crzossv OVr TCN HAS tire_ OF 'nW, NECESSARY • rF 'v rr+ WACTF MAN 94FN lfAN.-9Fr- In[ 18c.Signature of Alternate Facility(of Generator) Month Day Year Q z ' 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and re[yding systems) 20.Designat Faci ly Owner or operator;Cert' lion of&eipt of ha ous materials covered by the manifest except as noted in item 18a PrinfedlTn a Slgnalum w Day EPA Form 8 _-22 ev. } PreOiXs Aitions are obso to: ESIGNATED FACILITY TO GENERATOR.