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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFESTC A L D B C 4 2 4 8 1 800624-9136 013997 `8 JJ K 5.Generator's Name and Mailing Address Att: LAUREN AKINS Generator's Site Address(if different than mailing address) OLD DOMINION FREIGHT LINE INC. OLD DOMINION FREIGHT LINE INC. 500 OLD DOMINION WAY 601 DARCY PARKWAY THOMASVILLE NC 27360 LATHROP CA 95330 Generators Phone: 1 ::11 A A 9 9 r, 7 R n 6.Transporter 1 Company Name U.S.EPA ID Number s Patriot Environmental Sefvices C< A D a 5 3 8 6 6 7 9 4 7.3ransporler 2 Company Name ". U.S.EPA ID Number Ti e,P -w 74 :5 8.Designated Facility Name and Site Address U.S.EPA ID Number CROSBY&OVERTON 163E WEST 17TH STREET I-ONG BEACH CA 903813 Facility's Phone: Rf 977-679P C A D V 2 8 A 9 9 0 1 9 ga_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity WIJVOI. 1• UN1993,WASTE Flammaable!igtks,mos. D001 , 551 '. z 2. _tri t C, OJT, ' L h-TP 0U1 (r ff.o' I 2 . 1 _e_...-..3._ _._.. VD I -PF w ; 33�_ 3. 2-1 4. 2..0 0 14.Special Handling Instructions and Additional Information USE PROPER Pig, JCB f€ 08- !3-00iil _.- (PET•RGCHEth PO H155166--19) 3.)LP56083_. 0 4 1.0015 V U 11r 1 ,, 7 o 3-7 f 0,V -2-RC 15. GENERATOR'S101FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeledlplacarded,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 Prlmary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 1 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 small quantity generator)is true. G neratorsl0f1i Printedffyped Name{ Sign Lure K. Month Day Year .International Shipments t F- 1:1 Import to U.S. ❑Expert from .5. Port of enlrylexit: Z I8Transporter signature(for exports only): Date leaving U.S.: � 17.Transporter Acknowledgment of Receipt of Materials Trans ;lsr,joP�rintedlTyped Name Signature Month Ray Year IL -Aa � JUS:L 1, i G� c ... 5�'�'' < ?_ 1 aTransporter 2 Printedffyped Name Signature Month Day Year � _:/ Irl/ '.r .Ss' I� l..µ� -...--•-. � �!;- �.-: 18.Discrepancy f 18a.Discrepancy Indlca(ion Space ❑ quantity ❑Type ❑Residue ❑Partial Rejeclion ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) qje R1F3tE24CED WASTE WAS RECFTVED.RANDUEW N WD�fi4Ni�tld Fro V _ UNDER f)tSPQSAL,TREATMENT OR RElJS&CROSBY k OVFRTON.1NC.OPERATET}iE FACIISiY ra Facility's Phone: pj Rb S GRANTED TO PEFM, b GED BY TtQd DE:'ARThiFNT OF TOXIC DNE SUBSTANCE CTliE p f rSu)NS FS OF ty i'f}tEiJ'1V[RONMFNI'ALPRO"i F.(-MON AG Y IN ACC TOMMWI'1}[UAPPLICABLE w18c.Signature of Altemate Facility(or Generator) TM RFsouRCE CON ^ F- L�DFJtAL AND STATE RBGuLATIONs. CROSBY t OVER1'oN WAS"f'E rHAS BEEN E ND�r� Year Q THE�ENC8D.wAM AND ALL THE Z {-FRMr S TO ACCFpF w19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatnfi f, nd recycling systems) LU 1. 2, f 3. 4: 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month� / Month Day Year EPA Form74Q Z Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR