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RESIDUAL INFORMATION PICK UP RE EST <br /> SHELL TERMINALS AND PIPELINE <br /> This form must be filled out completely and all required analyses attached. FAX or E-MAIL to the <br /> Residual Disposal Coordinator for characterization and transportation of material. <br /> RDC AREA PHONE FAX <br /> Sherell Hcidt CA,HI,OR,WA 7131241-5036 713/241 7646 <br /> Nancy Groves AL,LA,CO,IL,IN,KS,KY,MI,MS,MT,OH, 1131241-0858 713/241-2997 <br /> TX <br /> SITE INFORMATION <br /> Site Contact: Daniel E O'Malley _ <br /> Region/District/Area: Western Phone: 209-342-8292 Fax: 209-835-5974 <br /> Facility Address: .. .25705..Patterson Pass Rd _ <br /> City: Trac State: Ca ZIP 95377 County: San Joaquin <br /> Location Number: <br /> Incident No.: Charge Code/SAP/Expense/AFE <br /> Send invoice to Name: Domingo Nunez Address: 25705 Patterson Pass Rd <br /> City: Tracy State: Ca Zip: 95377 _ Telephone: 209-834-8789 <br /> Material Description: Free Liquid ❑ Yes x No Project x Remediation❑ Spill ❑ <br /> Pliaull special L.W.I. #25(For Heat exehan er <br /> Process generating this residual: (Be specific-for example:blasting of floor of crude oil tank 306) <br /> Yard Clean U <br /> Accumulation Date: 6/4109 Sampling Date(if applicable) <br /> Type of container. Drums—How many 1 Type: _55 Gallon open head,ring lid <br /> 55 gallon drum Drum ID Numbers: D-1 _ <br /> Bins—How many Size: Volume in Bin <br /> Size: Volume in Bin <br /> Bin Supplied by: _ Bin Number(s) <br /> Bulk pile Size (cubic yards) <br /> Other <br /> Any special requirements for drum pick-up? (Rusty,missing parts, leakers, etc.) <br /> Comments/Local Vendor Suggestion: <br /> Form filled out by: Daniel E 6'Mal1e Date: 6/15/09 <br /> Phone: 209-342-8292 Fax: 209-835-5974 <br /> E-Mail Address: Daniel.omalley&hell.com Company: Shell Pipeline Co <br /> NOTE: IF VERIFICATION FORM IS NOT RECEIVED BY SITE CONTACT WITHIN FIVE(5)DAYS, <br /> NOTIFY RESIDUAL DISPOSAL COORDINATOR BY PHONE. 11/10/04 <br />