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06/26,'96 14:09 FAX 714 520 3570 SHELL HAZ WASTE _ 0003 <br /> 5110110 of Califor"kiII—Firwen,reehill Frohecrion Agency <br /> Form Approved OMD No.2050-0039(&*m 9-30-PA) See Ifisi.ructions on back of page 6. Doom%'I of Toxic Subriarcm Camra <br /> Pkcwprim ortype, Socraftefft,Cei-hri-rie, <br /> 1 04"101 US EPA 10 N4, Manifest Document 2. Pogo I the dtaclad areasUNIFORM HAZARDOUS is not"nd by Federal law. <br /> Information Ii. <br /> WASTE MANIFEST <br /> 3. Genereft,'s Name and Mailing Address <br /> C4 <br /> WIA 4. Generator's Phone 7 <br /> es 5. Transporter I Company Nemo 6. US EPA ID Number <br /> 7. Transporter 2 Company Name 3. J5 EPA ID Number <br /> 711 <br /> 9. Designated FaI Name and Site Address TO. VS EPA 10 Number <br /> vmw <br /> A 1111 <br /> -:-:5t 77R;RR ci <br /> In< <br /> U <br /> Z 11. V3 DOT Description(including Proper ShippiI NameHazardClass,and ID Numbr) 12. Co oir. 13. Tara) 14. Unh <br /> 01 • "d!, No.4 1 Type ouardity %"/Vol <br /> CM <br /> ap <br /> do N E <br /> It <br /> c. <br /> 0 <br /> LU <br /> 5- d. <br /> U <br /> 1AJ <br /> 0 <br /> 0, <br /> Ce <br /> 0 15. Special Handling Instrw0ions and Addlitioniol Inforr"I <br /> Z l- <br /> -< t?VOID CONTACT i41 7-H SERVICE C—TPT7-CN <br /> LU :24 "CUR EMERGENCY 2141 2. PlAi"41 <br /> -11DkI. -p. <br /> 16, OWERATOR'S CERTIFICATION: I hereby declare that the contents of me consignment are fully and accurately described above by proper shipping name and are dosOU4, <br /> packed,marked,and labeled,and are in all respects in proper condition for tranxport by highway accardi"to applicable federal,stwo and international laws. <br /> IF I am a large qvonti?y generator, I certify that 1 have a program in place to reduce the volume, and toxicity of wrowe generated to*0 do" I have determined to be <br /> .w economir 11Y PraI and that I have selecled the Practicable m9+06 of A 11 m" . <br /> 496 va -"wage,or dispowl currently available to me%466h minimizes The pnesem and futurw <br /> threat to human health and the environment,OR, if I am a small quarnory generator, I have made a good faith effort to rninirniw my wcuft 99fwation and soled the best <br /> wcMe manocrem wi=method that i;available to me cod that I can afford. <br /> 0 I Printed/Typed No"w- nIDay Year <br /> — 1,4. 1 - if <br /> Z T 17. Transporter I AdEnovAedgevnent of Roceiel III mut"l, <br /> A' Printed/Typed Name ngnature Aortth D" Year <br /> Cc 14- <br /> a, Ia. Trent oder 2 AcItnovIrleciggmint of Rece;p?of Materials <br /> ru 4Month Day Your <br /> I Printed/Typed Name Signature <br /> 0 . <br /> Uj 19. D;screponcy indication 5pgcc <br /> U A <br /> C <br /> L <br /> 1 _20. Fac;IWY Owner or Operotor Certification of receipt of howidaws materiall covered Oy,this monifqvt except as noted In joeft% 19. <br /> PjEeedjypod Name Signature Month Day Ycar <br /> t <br /> I -1wT; <br /> DO NOT WRITE BELOW THIS LINE. <br /> QTSC 8077A (77/91) <br /> FDA F700—'!2 <br />