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r> Please print or type. Form Approved.OMB No.2050-0039 UNIFQRNMAZAR000S 1.Generator ID Number 2:Page I of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 4 2 '4 8 1 :7 18W 624.9136 02®3 5117 4 JJ K $&5t68 161jT LINE INC. �t;�I�f'I� 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMASVILLE NC 27360 LATHROP CA 95330 Generator's Phone: 3 3 6 82 2 5 7 6 0 6. anspq ter ompany Name U.S.EPA ID Number atrfatnv1lQFlrflBf� �«SBrV#CBS C A D 0 5 3 8 6 6 7 9 4 7.Transporter 2 Company Name U.S.EPA ID Number 8:�ci tYAlamAddress U.S.EPAID Number 1630 VILEST 17TH STREET LONG BEACH CA 90813 Facility's Phone:800 827-6729 ICA D 0 2 8 4 0 9 0 1 9 9a, 9b.U.S.DOT Description(includ'mg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. ON RIC T 0 LU 4. 1A al li kAuct fnd bn'1'o66ion19-=00454 1)LP51690 P$.TROCHEM PO# H36987-19 CA4972,CA5034,CA5050,CA5123 15., q� NERATOR'SfOFFEROR'S.CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described ahova'by tf 6 proper shipping name,and are classified,packaged, .:�t.... 3v "rharlte8 and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental tegulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. t I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a smal}quantity generator)is true. Generator>sf fferor's Printed yped Name Signature 0,y) -VA/ QA� IMofth ay Year n nk 116.International Sirpments [= ❑Import to U.S. ❑Export from U.S. Porto en lexis: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name Signature Month Day Year CL Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a:aiscrepancy,lndicatian Space:,. 'QuanA +s , r ,, ❑" ta JF7) r n n 5 • . ❑Residue " ' OPartiaiRe ect on ❑Ful1 Re )yi 13 ❑`type j jection AhD STORM FOR 5O85EQLrpyT p f C; E rt.t"lLr: CR .V1m,1TS GEtl,:�f7';i T:. '}"T r�. •.L: ".G':LZtib. S�fT e�C �I(�bi Eli Fnrm F>- 18b.Alternate Facility(or Generator) i 1t 41i. :. .. A!. OT:c;_ :�,. ^' , CoN'M0t Enid ID Number TfEE RFsf�tEftes C�;:r„ CY 1;.h:xrIE )ANNE V, `J kTd1 t `"`•%t'i"::-,'i.`fD :_T•r, : :�`„CF' OF f97- f 77fE PROVISIOAIS OF C 1 ERAL AND 53:1"f' E L: i,•e:- 7C `1'0'32 V.TIH APPLICABLE Q I�FAMI7'S 't'O ,.CCuu:T'7}IE E,;� ... - .3 A1.L OF -nip h SARY �- Facility's Phone: ACICnru3u+uLY C:" Z WAYAIi ti4u�J-C 71l4 W"o, zs JfA w 18c.Signature of Alternate Facility(or Generator) Month Day Year tR Z U) 19.Hazardous Waste Report Management Method Codes(i.a.;codes.for hazardous waste treatment,disposal,and recycling systems) LU 2. 13, 4. 20.Designated Facility Owner or Opera%Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a PrintedlTAlamo Signature Month Day Year EPA Form 87013ev.12-17) Previous editions are obsolete. `" DESIGNATED FACILITYTO GENERATOR