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Please Dnnt or type. (Form desianed for use on elite (12 -Ditch) tvoewriterA ' r Form Annmved.OMR'Nn 2050 -nom EPA Form 67UU-22 (Nev. 3 -US) Nrevwus editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) 11850.2072 UNIFORM HAZARDOUS 1. Generator ID Number * 2. Page 1 of 3. Emergency Response Phone 4. Manffest Tracking Number WASTE MANIFEST CAL0=70082 1 1 1 (800) 424-M0 007615936 FLE 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) 7 -Eleven, Inc. 14M P.O. Batt 80741 3UG Nksi EIiia Hn'12 Ranchd Saida M arite, CA 02088 aodsan, CA ��49 Generators Phone: (049) 430-5200 6. ransporter 1 Company Name U.S. EPA 10 Number 6ELSHI RE CAR00.01.83013 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.SIEPA ID Number U.S. EcaI@gy, Nevada .Opzl ions NVT330010MO Hiway 05, 11 utiles S. of e --&y Beatty, NV 8W03 Facility's Phone: (775) 553-2203 ga gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WtNol. o 1 UN3175, Solids. Containing Rnmmab1e Liquid, n.a.s., 4.1 P 332 °0018 W PG II (Contains Gasoline) (ERG 0133) 8 Z 2. W 3. 4. 14. Special Handling Instructions and Additional Information �� B: 4 ®� �l Generator is a RCR A CESCG und�40 CFR waste ii•exomp't from State 201.5. D018 code represenlZs 1asaste thzt iE end Federal Land bisposal 7-11 CCN: 313710 RCRJA identified blIA not. RCRA mguleed. Rc>stritgians. PROFI LE 0 070214257-0 15. GEN ERATOR'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, 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 terms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a) (I I am a large quantity generator) or (b) (if I am a small q 'b nerator) is true. Generators/Offerors Printed/Typed Name Signature Month Day Year Larry Maathart of BEST an i2shaif of gWnm-tor. r. J t_ 16, International Shipments 'f ❑ Import to U.S. ❑Export from U.S. ort of entry/exit: Transporter si nature for exports only): " Date leaving U.S.: w 17. Transporter Acknowledgment of Receipt of Materials A' TransportP nted/Typed Name ; ,, Signature n on a�yp rear � ��a ly a p � �( LL Z Transporter 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. Alternate 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 - Z H19. Hazer ous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1, F113a 2. . .. I. 3. 4. 20, Designated Faa ity Oner or Operator: Certification of rq6i of hazardous materials covered by the manifest exce s to in Item 182 Printedryped Name Signature Mon e 11MXr Var L EPA Form 67UU-22 (Nev. 3 -US) Nrevwus editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) 11850.2072