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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 ' <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number2.Page 1 of 3,Emergency Response Picone 4 rdanlrest Tra ng Number <br /> WASTE MANIFEST CAD981465255 l94"90-S70113000809413 F L E <br /> S.Generator's Name and Mailing Address Generators$ite Address(W different than malting address) <br /> 7-Eleven, Inc. 7-Eleven 17334 <br /> P.O.Box 80741 4501 N. PERSHING AVE <br /> Zancha Santa Margarita,CA 92888 STOCKTON, CA 95M7 <br /> eneretora Phone: 249 4�'5� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> PELSHI RE CAR000183913 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fadfity Noma and SileWrM U.S.EPA ID Number , <br /> US Ecology,Nevada Operations <br /> Highway 95, 12 miles S. of Beatty NVT33001000R <br /> FPae�aV 89003775 �. <br /> 94. sb.U.S.DOT Dascriplon(mcludirrg Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tvfal 12.Unit 13.Waste Cedes <br /> HM and PaelbngCroup(tany)) rNo, Type Quantity "Mi. <br /> 1 352 <br /> a Solids, Containing Flammable Liquid, n.o.s.,4.1,UN3175, P P <br /> X <br /> ZLLI <br /> 2 <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Addil'ronal InformationF11111)LAM AT no, <br /> WEAR ALL APPROPRIATE SESI:1476gO LINF:-AFRX�:.1Q�-AI <br /> ERR- 139 PROTECTIVE CLOTHING. '`gym.i':pP��tra 1 <br /> � � :'t�ftlalui�61lTB5Q i <br /> .asrodt�r`u <br /> 15. GENERATOR'SrDFFERO 5 CERTIFICATfON: I hereby declare that the contents of this ca*mmant are fully and acasateiydescribed above by tte proper shipping name,and are classified,pactraged, <br /> marked and abeledrplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If expel shipment and I am the Primary <br /> Exporter,I certify that the contents of this Consignment Conform to die terms of the attached EPAAcknovAedgment of Consent <br /> I certify that the vraste minimization statement identified in 40 CFR 26227(a)(f I am a large quanlitygenerator)or(b)(if I!pr a Jna8 quantic generator)is true. <br /> Generate erors PrIntedlTyped Home monm Uay fear <br /> Lar-y Moothari:of BITS) an behalf of generator Z Z0 0 <br /> 16,tniemaficnal 5hipmen!s ❑Export from U.S. Po n !exit: <br /> � ❑Import to U.S. uY <br /> z Transporter si nature(fore s on n U.S.: <br /> LM 17.TransporterAcl-uMedgment of Receipt of Materials <br /> Transport.,1 PrintedlTyped Name gna re an ay Year <br /> Cn <br /> Transporter 2 PrintedrTyped Name Month Vay Ybaf <br /> rr <br /> 18.Discrepancy <br /> 1 Ba.D,screpaccy Indlcaccn Space ❑Quantity ❑Type ❑ReMltlue ❑Partial P iactla. ❑Full Rejection <br /> Manifest Reference Nrrmher: <br /> 18b.Altemale Faciliy(or Generalor) U.S.EPA ID Number <br /> J <br /> U <br /> L� Facllll s Phone: <br /> w 18c.Sigriature ofAltemate Facilt!y(orGenerator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e,Codes forhazardous waste treatment,disposal,and recycling systems) <br /> LLI 0 1. 2. 3. 4. <br /> i <br /> 20.Dssignaled Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Ba <br /> Printed/Typed Name signewre Month Day Year <br /> EFA Form 8700-22(Rev.3-05) Previous eftris ere obsolete, DESIGNATED FACILITY TO DESTINATION STATE tIF;REQUIRED)' <br />