COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

DTSC.03353.0350 Please print or type. (Form designed for use on elite (12 -pitch) typewriter.)rEoi Form Approved. OMB No. 2050-0039 LPA form btuu-z2 (Kev. "o) Previous eamons are oosotete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIKtU) 12157.1410 UNIFORM HAZARDOUS 1 Generator ID Number g' ® ® ® O 3 2 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ® 1 (600) 5124-9300 008 6 g 8 7 8S FLE 5' Generators Name and Mailing Address Generator's Site Addressif different than mailing address) 7 -Eleven, Inc. 7 -Eleven 14113 P.O_ Box 80741 3040 [est Benjamin dolt Drive Rancho Santa Morgarits, CA 9298 Stockton, CA 95219 Generators Phone: (9 9);460-5200 6. Transporter 1 Company Name U.S. EPA ID Number BELSHIRE CARO O O I 0 319 13i 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number U- S. Ecology Nevada Operationz M V T 3 3 0 0 2 0 0® O � WWI S_ of Beatty Slateay Y. 1 Faality'sPhone: (775) 553-2203 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, W. Containers 11, Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity 1MNol. 1 UN3175, Solids, Containing Fl—able Liquid, P 352 *DOl cc n.o.s., 4-1 BG II (ConlZaifas Gasoline) (ERG #133) f� z 2 L 3. 4. 14. Special Handling Instructions and Additional Information t3aste is e31 empt from B ES I a 2 5 6 5 7 9 Generator is a' RCRA CESGZ under 40 CPA Stain 'and Federal Land 7-11 CM 613710 261.5. D018 code represents waste that Disposal Restriations. is RCRA identified but not RCRA regulated. PROFILE $ 070214257-0 15. GEN ERATOR'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, 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 Exporter, I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent 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 small qua erator) is true. Generators eroes Printed/Typed Name gnature "I Month Uay Year Larry Hootfiart of BEST on bahalf of generator J i- 16. International Shipments ❑ Import to U.S. El Export from U.S. Port of entry/exit Transporter signature for exports only): Date leaving U.S.: w 17. Transporter Admowledgment of Receipt of Materials Trans 1 Printed/Typed Name Signature Month Day Year N QTransporter 2 Printed/Typed Name Signature Month • Day Year H' 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Altemate Facility (or Generator) U.S. EPA ID Number J U Q . LL Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q 2 19. Hazardous Waste Report Management Method Codes (.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. � 2. 3. 4. 20. Design' acr7ity Owner or Operator. Certification of recgtpt of hazardous materials covered by the manifest ex as noted in Item 18a Prinled7T imwA � Sigre h4on Oay Year LPA form btuu-z2 (Kev. "o) Previous eamons are oosotete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIKtU) 12157.1410