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Please print or type.(Form designed for use on elite(i2-pitch)typewriter). Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1•Generator ID Number - 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST -C A L 4 '0 0 4 2 4 8 1 7 a 1 1 800 624-9136 01389-7401 JJ K <br /> 5.Generalor's Name and Mail' Address All:LAUREN AKJNS3enerator's Sile Address('d different than mailing address) <br /> OLD DOMINIONFRE lPHT LINE INC. CLD DOMINION FREIGHT LINE INC. <br /> 500 QLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generator's Phone: 3 3 6 8 2 2 5 7 & 0 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Patriot Environmental Services C A D 0 5. 3 8 6 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.17es1gr�lgdil-ityarL!@ andi�eO dtess U.S.EPA ID Number <br /> t 1630 WEST 17TH STREET <br /> LONG BEACH CA 50813 <br /> FaciiitYsphone: 800 827-6729 C A D 0 2 8 4 0 S 0 1 9 <br /> ga• 9b.U.S.DDT Description[nduding Proper Shipping Name,Hazard Class,ID Number, 10.Conlalners 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouantity WLIVOI. <br /> 1. <br /> UN 1960,WASTE Aerosols, flanwable,(each not exceeding i L C}001 214 <br /> capacity) <br /> a <br /> 0 <br /> 2.'E • <br /> z 2- NON R .- <br /> CRA HAZARDOUS WASTE SQLID(Rt3SCRBENT WITH 352. <br /> corn MOTOR OILY <br /> o a � D0 P <br /> 3. NOKI RC R�, AZA )0Vc 0101 <br /> WIT <br /> In"MO-19-000164 _-t,RETROCHEM -erg- x,35217-19) - A A ff- 2_15 <br /> �xl [ ) "GD . - . <br /> 15. GENERATOR'SfOFFEROR'S CERTIF[CATION: I hereby declare that the contents of thls consignment are fully and accuretely described above try the proper shipphg name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condilion for transport according to applicable tntemational and national governmental regulations.It export shipment and I am the Primary <br /> Exporter.t certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent <br /> I certify that the waste mintmizalion statement€dentfied In 40 CFR 262.27(a){if I am a targe quantity generator)or(b)[f I am a small quantity generator)is true. <br /> Generale Offerors Printedfryped Name Signature Month Da Year <br /> (��►�`-% - t 01 1 1 <br /> --t 16.International shipments <br /> i— ❑Import to U.S. ❑Export fmm U:S P of trylexil <br /> Transporter signature(for exports only): Date leaving U.S.:. <br /> 17.TmnspoderAekwMedgmenl of Receipt&Materials <br /> Trarteri Prin riff pe¢ a Sign Month ay YeCLa <br /> N � � <br /> Q Transpeder2 Printedffyped Name Signature f f Month Day Year <br /> qC i <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity [:]Type ❑Residue Q.Partial Fieje,�M ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) DISPOSAL--TREATMENT OR REUSE,CROSBY&OVA aSLQUENr OF [ <br /> ! <br /> TtiE FACjj1y�rNlJ:p <br /> J S-�ANTF�TO�M.BY 713E DEPARThSpNT Op TOXIC Sit 95TANCE CONTROL 71pGi:net <br /> L] '+'rnt TILE FANIRONMENrAL pRaFECl7ON AGENCY ACCOHl7ANCE Wl J{ONTROOV OGI s CSF <br /> ti Facilityrs Phone: n-M RESOURCE CONSERVATION AND RECOVFRy OF 1976.CE wr, w <br /> rni <br /> LU 18c.Signature of Alternate Facility(or Generator) . . r UV[-2TON HAS AL. OF " �i p."May Year <br /> 'FRAfff3 7l7 ACCEPT 71rE REFERENCED WASTE AND w1.L Q <br /> 'r'CdRA�GCY TME WASrf HAS a• N <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1 V 1 . H) <br /> 2. 3. , �I 14, <br /> � <br /> 20,Desegnated Facility Owrleror Operator.Certification of receipt of hazardous materials covered by the manifest except as rioted In Item 18a <br /> Pdnledfr Name S1gnaWre Month Day Year <br /> EPA Form 8700.22 ev,3-0 Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />