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DTSC.'038 2 5. 08)1 4 <br />Please Ddnt or tvoe. (Form desioned for use on elite (12-oitrhl tvoewdter ) <br />P- e -n, d nnea nim mrr)-nmo <br />..1-2415.229a.:.., <br />Q <br />EQu�o1 fr• <br />UNIFORM HAZARDOUS <br />J1.Generat.rIDNumber <br />'2 <br />12. Page 1 of <br />3. Emergency Response Phone <br />14. Manifest Trackin Number <br />C I C <br />WASTE MANIFEST _ <br />C A L 0 0 0 2 7 0.0 8 <br />1 <br />(800) 424-9300 <br />0 O 9 08329 TLE <br />r L C <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) - <br />7 -Eleven, Inc. 7 -Eleven 14113 <br />P_0_ BOX. 80741 3040 hest Benjamin Holt Drive <br />Rancho Santa Margarita, CA. 9ii�� $$8 Stockton, CA 95219 <br />Generators Phone: (9i ) 460-520 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />T. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />S. Eco gy11Ne #da ¢perrions 8 V T3 3 0 0 10 0 0 0 <br />�gttyY NVQ ' $90 ea s a Batty <br />FacilitysPhone: (775) 553-2203 <br />ga. ' <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />' <br />13. Waste Codes <br />No. <br />Type <br />HM . <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />0 <br />1 UM173, Solids, Containing Flssamable Liquid, <br />B <br />2321.*Doll <br />I <br />F <br />Xn.o.s., <br />. '4.1 9G II (Contains Gasoline) (ERG. <br />$133) <br />�� • <br />:20 <br />z <br />2.'' <br />LU <br />3. <br />4. <br />14: pKW Handling Instructions and AtIftonal.1nfonnation <br />y�� tiG: waste .is! vaceapt firm BEST : 2 69.695 <br />6fsaasator is s MAa CE�Q6 4d• <br />; under State and Federal Land :. fz??i' <br />261,5-. D018 QOde lieyrss�nts �raste that Disposal", ` CCN• Q19?1Q. <br />Restrietio <br />Li ACRk bugs AM <br />ideatifired not - . �. <br />coma, pROFLL $ 07021425770 . XS :s:: <br />15; ,' GENERATOWSIOFFEROR'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 international and national governmental regulations. If export shipment and I am the Primary <br />Ekporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />'1 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 --quantity generator) is true. : t <br />eneratoesl erorsPrinted/IypedName bignalure ay• -..,ear, <br />Larry Moothart•-of B89I on beba].f of 9 -en rator '�; 2�'; <br />.-J <br />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 />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />a <br />rensporter 1 Printed/Typed Name T ignature on ay ..1' ear <br />QTransporter <br />2 Printed/Typed Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity r ❑ Type ❑ e)ectFull Rejection.. <br />❑ Residue pial ion ❑ <br />1 t � <br />r, N." F � <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />LL <br />• <br />Faclli 's Phone: <br />W <br />i8c. Signature of Attemate Facility (or Generator) Month Day Year <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />2. <br />3. <br />4. <br />20. De -gna Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br />PrintedrTyped 1 Sig atu Monty I)ay'J% <br />fY/eater <br />N11e,. <br />EPA <br />1. 870 ) Previa s edition are obsolete. nFRI ,Nb n FA( II ITV Tn GFNFROTnR RTATI: 1IF R <br />..1-2415.229a.:.., <br />Q <br />EQu�o1 fr• <br />