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PI <br />9TSC.0331,4.0050 <br />ease print or type. (Form designed for us"n elite 412 -pitch) typewriter.) <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Pad t <br />WASTE MANIFEST C A L 0 0 0 2 7 0 0 8 2 1 <br />5. Generator's Name and Mailing Address <br />7 -Eleven, Inc_ <br />P_0_ Box 80741 <br />Rancho Santa Margarita CA 92688 <br />Generators Phone: (949) 460-5200 <br />IRE <br />�r 2 Company <br />Form Approved. OMB No. 2050-0039 <br />of Emergency Response Phone 4. M ife t cK umbe <br />(800) 924 9300 �g 7`)"69 FLE <br />Generators Site Address (if different than mailing address) <br />7 -Eleven 14113 <br />3040 West Benjamin Holt Drive <br />Stockton, CA 95219 <br />ID <br />o. uesignateo t-aanty Name ana bite Aaaress U.S. EPA ID Number <br />2DeM00 n o K rdoon CAT060O13352 <br />200 i Aameda St_ <br />Compton, CA 90222 <br />Facility's Phone: (310) 537-7100 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes <br />HM and Packing Group (d any)) No. Type Quantity WINol. <br />IX S{ 1' UN1203, Gasoline Mixture, 3, PG II DM ^ G 134 <br />� L <br />z2. <br />C-5 c5 <br />14. Special Handling Instructions and Additional Information WEkR ALL APPROPRIATEFOLD LAB <br />ERG#: 128 PROTECTIVE CLOTHING BESI : 2 5 4 9 $ 5 UNE. <br />Gasoline & Water 7-11 CCN: 613710 SIDE OF <br />MATERIAL <br />5 TAB STIC1 <br />rnssu om <br />15. GENERATOR'S/OFFEROR'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 terms 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 targe quantity generator) or (b) (if I am a s q l ly generator) is true. <br />11 Larry Moothart of BESI on behalf of generator <br />J 16. Intemational Shipments <br />H ❑ Import to U.S. Export from U.S. <br />Z <br />Transporter signature for exports only): <br />r� 17. Transporter Acknowledgment of Receipt of Materials <br />Port of entry/exit: <br />Dat2teavino U.S.: <br />wanaWnm <br />O <br />, r ,YNc..----- <br />QTransporter <br />2 PrintedrTyped Name 5igr1We <br />Month <br />Day <br />t- <br />18. Discrepancy <br />1 Ba. Discrepancy Indication Space <br />❑ Quantity 1:1 Type El Residue <br />Partial Rejection <br />Full Rejection <br />Manifest Reference Number <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />Q <br />LL <br />Facility's Phone: <br />LQ <br />18c. Signature of Altemate Facility (or Generator) <br />Month <br />Day <br />Q <br />Z <br />N <br />19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LLJ <br />1 <br />2. <br />3. <br />4. <br />Designated Facility Owner or Operator. Certification of receipt of ardous materials covered by the manifest except as noted in Item <br />Prt ted/T Name Signature <br />Month <br />Day 1 <br />Day <br />�, <br />160 <br />EPA Fo 8700 22 (Rev. 3-05) Previous editions are obsolete. DESIGNA <br />FA ITY TO DESTINATION <br />STATE <br />(IFQUI <br />12029.2092 <br />