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nrC'r' n A 1 n 0 n1 1 V <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Appi <br />UNIFORM HAZARDOUS 1. Generator ID Number 1 2. Page 1 of 1 3. Emergency Response Phone 14. Manifest Trackin Number <br />V ASTE MANIFEST CAL00270 0 0 8 2 r1 (800) 424-9300 00, <br />b 8 <br />5. Generators Name and Malting Address Generators Site Address (if different than mailing address) <br />7—Eleven, Inc_ 7—Eleven 14113 <br />P_0. BOX 80741 3040 Wezt Benjamin Holt Drive <br />Rancho Santa Margarita, CA 92688 Stockton, CA 95219 <br />r;vnnr tnMePh— (949) 460-52001 <br />ved. OMB No. 205HO39 <br />759 FLE <br />CAR000183913 <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />De n o K rdogctn CAT080013352 <br />6omppton, ACAS 90222 <br />Facility's Phone: (310) 537-7100 <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM and Packing Group (if any)) No. Type Ouantity WUI.VO13. Waste Codes <br />1. UN1203, Gasoline Mixture, 3, PG II G 134 <br />X � M <br />4. <br />14 Special Handling Instructions and Additional Information WEAR ALL APPROPRIATE �L010 LABEL <br />ERG#jE: 128 PROTECTIVE CLOTHING $ESI : 2 7 719 2 /X 5 C LINE. AFFIX <br />Garsoline 8 Water 7-11 CCN: 613710 / SMATERIALBIL <br />TAB STICKS 0 <br />LT196U O1M <br />15. GENERATOR'SIOFFEROR'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, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br />I 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 sm 1 quantity generator) is true. <br />Generalors/0 emrs PrintedfTyped Name bignature Month Day Year <br />Larry Moothart of BESI on behalf of generator — Z <br />—J 16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />X-17. Transporter Acknowledgment of Receipt of Materials <br />L <br />Transporter 1 Printedffyped Name Signature Month Day Year <br />�4.�,r 1 t �L Q •._ IL - - Z Z 11"1 <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />W 18c. Signature of Altemate Facility (or Generator) Month Day <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />G 1. 2. 3. 4. <br />21. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedfTyped Name Signature Month Day <br />Y92 56Y <br />.PA Form 8700-22 (Rev. 3-04 Prrevjo4CV6ons are obsolete. DESIG)WdfD FACT -0 DESTINATION STATE (IF REQUI <br />12537.0109 <br />