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' State of Cal,forn,o—Enverumr,ewol Protection Agency <br /> Form Approved OMB No 2050-OM9(Expires 9 3494) See Instructions on back of page 6 Department of Toxic Substances Control <br /> Please print or" Form designed for use on chte(12prrch)rypewrder <br /> Sacramento California <br /> UNIFORM HAZARDOUS I Generator s US EPA ID No Manifest Document No 2 Page I Information,n the shaded areas <br /> WASTE MANIFEST is not required by Federal law <br /> 4f 6r 10 v 5 i ,3a 0 Pi 4 of ! <br /> 3 Generator s Name and Mailing Address SHELL OIL COMPANY A <br /> HAZARDOUS :BASTE DEPF, <br /> P-0. BOX 4848 <br /> in 4 Generator s Phone t <br /> (30 (71It)5c0- .3.2 ANAHEIM, CA 92803 <br /> 5 Transporter 1 Company Now U EPA ID LgVf (- % CV ' 0 T"wdposlet',rr �L"iPd rr J <br /> I <br /> 7 Transporter 2 Company Name <br /> Q $ US EPA ID Number E Stab,Trmssporfer"s Ip:r - <br /> U - <br /> F Transporter's PhoneN <br /> Q 9 Designated Facile Name and Site Address <br />�Z g facility 10 US EPA ID Number G State Fadlit�s ID �+-' <br /> tin <br /> ! <br /> 2M5 PAP„R 'LsJ C "1 D 9 O c H F—Idy's Mone '� "� ► <br /> Z 11 US DOT Description(including Proper Shipping Name Hazard Class and ID Number) YNa <br /> Containers 13 Total T4 Unit <br /> T Quanr Wt/Val I Waste Number <br /> *-- l $lata <br /> G <br /> N E e A { P c'f �'l 1? �' EPA/Odw <br /> 00 N b Stave <br /> v E <br />' v A ther <br /> EPA/O <br /> 0 <br /> oho T c State <br /> O <br />' w EPA/Odor <br /> Z d State <br /> LU <br /> U <br /> w EPA/ONser <br /> J-`AddW.,%l Desenl hoes for Male als Listed Abort r r r ' 1 r K Handling Codes for Wasfts lsftd Abow <br /> alit” Y TANKS) AND FISERGLA SITE . PZM a lb_ <br /> LU -h I n 3 B <br />'� n� f41gi <br /> Q - c d <br /> Z ' <br /> Q 15 Special Handling Instructions and Additional Information u- <br /> 1 y GG r� q� <br />'Z AVOID r..ONTt�CT �.TH SKIN/E�f 4:.t-., �I h r r w T^ ` <br /> `i 1.3Y <br /> :14 L10Uics EMERGENCY ' r,'NE r UMPER '5011)LU <br /> r r <br /> J 16 GENERATOR S CERTIFICATION I hereby declare that the contents of the consignment are fully and accurately described above by proper shipping name and are classified <br /> Q packed marked and labeled and are in all respects in proper condition for transport by highway according to applicable federal state and international taws <br /> U <br /> JIf I am a large quantity generator i certify that i have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be <br /> EZ economically practicable and that I have selected the practicable method of treatment storage or disposal currently available to me which minimizes the present and future <br /> V) threat to human health and the environment OR if I am a small quantity generator I have mode a good faith effort to minimize my waste generation and select the best <br /> iY waste management method that is available to me and that I can afford <br /> O Panted/Typed Name SPOckature Month Day Year <br /> s a <br /> Z T 17 TrOMP,iter I Acknowled ement of Receipt of Materials <br /> w A Printed/Typed Name <br /> Signey Year <br /> � Month Da Yr <br /> F, r r' <br /> tam, s / �/� L ✓'1-J t���/ � [ t� c1 �1�. / -c <br /> P <br /> O 18 Transporter 2 Acknowledgement of Receipt of Materials <br /> w R <br /> T Printed/Typed Name Signature <br /> Month Day Year <br /> Q R <br /> LU 19 Discrepancy Indication Space <br /> sA <br /> Q F <br /> V A <br /> Z I 20 Fault <br /> Owner or O erptor Cerhhcatian of receipt of hazardous materials covered by this manifest except as noted in Item 19 <br /> T Prmted/Typed Nome Signature Month Pay Year <br /> Y <br /> 20&44160806-298L jS DO NOT WRITE BELOW THIS LINE <br /> Blue GENERATOR SENDS THIS COPY TO DTSC WITHIN 30 DAYS <br /> B022A (12/91) To P O Box 400 Sacramento CA 95812 0400 <br /> b" <br /> 0-22 <br />