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Please print or type.(Farm desigried for use on elite(12•pitch)typewriter.) Form Approved,OMB No.2050,0039 UNIFORM HAZARQOUS 1.Generator N7 Number. .,... .; ; ;( - is 2.Pagel of 3.Emergency Response Phone 4.Manifest Tracking Number WASTEMANIFEST... I C A L 0 0 0 4 .2 .4 .8 1 7 � =62"136 017116224 JJK 5.Generator's Name and Mailing Address v y''' .. 'r., IAS- .., . NSGenera$fs Site Address(it different than mailing address) LAURENCLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMASMLLE NC 273W LATHROP CA 9WO Generators Phone' 6.Transporter 1 Company Name U.S.EPA ID Number Patriot-Environmental SeMoes CA D 0 5 3 8 6 6,7 9 4 7. 'sporler2jCompany Name .. U.S.EPAID Number 8.Designated Facili ame and Site Address U.S.EPA ID Number CROSBY&OVERTON 1630 WEST 17TH STREET LONG-BEACH CA 90813 Facility's Phone: C A I3 0 2 8 4 .0 9 0 1 9 ge, 9b.U.S.DDT Descript on(including Proper Shipping Name,Hmrd Crass,ID.Number, 10.Containers 11.Total 12.Unit 13 Waste Codes HM and Padding Group[fu No. Type Quantity Wt Nal, a d' NUN-RC RA �IhA9vot)S UJAS7 t] D Q LU C u A U osP 4� Roo . P 3.ON 1 QGr,3 I? W A�-rt_ FI-AM MAP :F L�G�4l1DS • 0'S . 3. 1 ( [A-6 cot bm 5 ' IL 14.5ppeeaaal Noodlingg InsWotions and Add lienal Information f35E...P1ZOPE-R....PPE- TOB-..#_E38�18-00592. ......{.PET'-RQCHEM,.•-Pfl-.H:•`,j-4.■7 ,..}..... . ._.. ��-�:_�� -'1113 rC �f 3-F I 15, GEHERATOR'SIOPFEROR'S CERTIFICATION:I he try declare that the 6-Mend of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,and are tri all respects In propercondition for transport acwrdmg to applicable international and nations governmental regulatans.If export shipment and I am the P inwy. Exporter,I certify that the contents of,this consignment conform to the terms of the attached EPAAcknowledgment of consent. , I certify that the waste mtrllmization statement identified in 40 CFR 262.2T(a)(if I am a large quantity generator)or(b)[f I a sm U quantity generator]is true.. je7,toe7mesPrinleff` ame Sig ature Month ay Year . LU CL nan/(I C e 6 110 , Irr ..J 6. niernational5 i eels .. i- .. ❑import to U.S. ❑Export fro .S. Par'of enlrylexlt: x Transporter signature(for exports only): le leaving U.S.: 17.TranspoderAc7alovAedgment of Receipt of Materials Transporter 1 PrintedrTyped Name signature (r Month Day Year inH a 'UV 1:0 �o le: Q spoater2 Printed(Typed Name Signal, Month Day Year hr n 18.Oiscrepaney 16.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, 18b.Alternate Facility(or Generator) . wwsrE wAs REt�rvm,HANDLED"'" l�REfTJt>ICPD, U I)ISPOEFERII FJ�T r.OR REUSE CRUSBY A:aYF3tTUK INC UPF]tw T}IE FAC[t Tr1 i3NUFF LL FaCalt]rs Phone: yp1iM1"rs GRANrEo,To T}[FJ�r.Bir THE DV ARTMENT DF'i'r1x1C SUBSTA wrr TjjE OL.RO LSSONSOF rE F7lYiROIihSr:NFAL vROTE7CrrON AGENCY Al7L'UFt7JAl GEs IEE wrlil.OAPKICADU C3 18c.Slgnature of Alternate Facility,(or Generator) THE RESOURCE ay Year }^(pf]tHL:Attn STA REGUL"ONs. �WABY ANQ ALL THE WASTIl HAS eT H+� . Z pMmas-M ACCF�f I"REFT•3'EHr:W , N19.Hazardous Waste Report Management Method Codes(i.e.,oodes forhazardous waste t raaWr l;an_d recycling systems) w 1 Ll ) m � :1I H ,). . I 3. 20.designated Facility Owner or 0 rater.Certification of receipt of hazardous materials owered by the manifest except as.ridted.in Item lila !!! PrinledlT�yped-Name r Signature Month day Year EPA Farm 8700-220v.3 05} Previous editions are obsolete. °- DESIGNATED] FACILITY TO GENERATOR