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NON-HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 18006249136 O D F L - LAT - J AN 2 0 <br /> 5.Generators Name and Mailing Address Att'LAUREN AIq N`=• Generalor's Site Address(d differerl than mailing address) <br /> OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. <br /> 500 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generatoes Phone: 3 25760 <br /> 6.Transponer 1 Carnpany Name U.S.EPA ID Number <br /> Patriot Environmental Services C A 0 5 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 13,MI OV eRrO N Address U.S.EPA ID Number <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facile sPhoae: 600 827-6729 C A D 0 2 8 4 0 9 0 1 `? <br /> 9.Waste Shipping Name and Description 10.Containers 11.ToW 12.Unit <br /> No. Tye WtNd. <br /> 'NON HAZARDOUS WASTE SOLID-FOOD STUFF-6REAf] �� � Y <br /> MAKING FAT,STARCH, BEEF BROTH, DRIED SUGAR, <br /> Q MAYONNAISE,SALT,FLOUR <br /> u! <br /> 'NON HAZARDOUS WASTE LIQUID-FOOD STUFF 00 � Df boo f <br /> a� 'F <br /> 4. <br /> 13.Spedal Handling Instrucfions and Additions!Information <br /> US>; E'RC5PER PPE .70E 0 0e-20- 00004 /)}11 - ,8-7__ 3 1!087.9 11ETR0,7HEM PD# H-7248-2 <br /> 14.GENERATOR'MFFEROR'S CERTIFICATION:I hereby declare that the contents of Ibis consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labefedlplacarded,and are in all respects in proper condition for transport according to,Aqk,able Internsfipnal and rat oral govemmerdal regulations. <br /> !os'slOfter Print ^ Month Day Year <br /> +Lau !` o I" imccox Y , '(]izD <br /> _j 5.tnternational Shipments1:1 <br /> ❑lmpvn fo U.S. Fxpor<}rcm Port d entrylexit: <br /> — <br /> Transporter Signature for exports Dale leaving U.S.: <br /> w 16.Transporter Acknowledgment of Receipt of Materials <br /> LLF <br /> Transporter 1 PrintedlTyped Nam* <br /> A �) Signature Month lDa'yy Year <br /> a ►V V� 01 1 <br /> aTransporter 2 PdMad+Typed Name Signaturr Month Day Year <br /> IrH <br /> 17,Discrepancy <br /> 17a.Discrepancy indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑FA Rejection <br /> Manifest Reference Number. <br /> r 176.Akemate Facility(nr Generator) U.S.EPA ID Number <br /> to <br /> C.1 <br /> uu. Faculty's Phona. <br /> bj 17c.Signature of A►femate Faa1ity(or Generator) Month Day Year <br /> a <br /> x <br /> c� <br /> N <br /> o <br /> 18-Designated Facility Omer or Operator.Certification of receipt of materials covered by the manilest except as noted in Item 17a <br /> PrintWITyped Name Signature Month Day Year <br /> 169-BLC-4 5 11977(Rev.9109) DESIGNATE❑FACILITY TO GENERATOR <br />