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Arkansas Department of Environmental Quality <br />Hazardous Waste Division <br />tP.O. Box 8913, Little Rock, AR 72219-8913 <br />�+ <br />• Telephone: (501) 682-0833 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter) <br />Form 8700-22 (Rev. 9-88) Previous edition is obsolete. I`Ct�ICQATf1R INITIAI rOPV <br />UNIFORM HAZARDOUS <br />1 Generator's US EPA ID No. <br />2. Page t <br />nPpfuvvu. VINO rvu. cUau-uuo& <br />Information in the shaded areas7not <br />WASTE MANIFEST <br />H 1 1 1 0 0 0 8 <br />7Manife�st <br />7Document No. <br />required by Federal law. <br />5 71 <br />of 3 <br />3. Generator's Name and Mailing Address <br />A. State Ma fest Documents NNumber <br />"a JQAQUI• coax" <br />AR-O <br />1810 a amu"05 <br />.71 <br />1 <br />B. State Generator's ID <br />PPQc" 1, CA 95201ATTIf: ALISQH HIID80Y <br />4. Generator's Phone 4209) 468-30616 (209) 468-3066 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />9mith Systems Transport, Inc, NlE D 4 8 6 3 8 2 1 3 3 <br />H- <br />D. Transporter's Phone (800)884-2597 <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E. State Transporter's ID <br />H- <br />F. Transporter's Phone <br />9. Designated Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />TZRIH <br />309 AWNUCAS CIRCLE <br />H. Facility's Phone <br />2L DORAD4i, AA 71730 <br />A Q 0 0 6 9 7 4 8 1 9 2 <br />(870) 863-7173 <br />12. Containers <br />13. <br />14. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Class and ID Number) <br />Total <br />Unit <br />1. <br />No. hype <br />Quantity <br />VwVol <br />Waste No. <br />G <br />.1ruiWASIX I + + , r (tab Fiack) + <br />E <br />744520) <br />N <br />R <br />A <br />b. + ValdZ5, Irts 11, Q <br />Tar, ietrollits Dlsttlates), (pt: 744521) <br />T <br />° <br />P <br />■/R <br />n. , <br />(Lab-pack)(DOT-3-13192), (pf: 744524) <br />r <br />E, <br />P <br />H/R <br />d <br />IIi (Lab-psCK)(V0T-E-13192), (pr: 769884) <br />t. <br />D III, <br />C 3 % <br />J. Additl n 3cn terms ,sted ,' C: ,,. <br />K. Emergency Response Information: <br />) *'� 11D: 769884 (: ;� ) i <br />Ili�'OT1iAC <br />411 <br />8840)535-5053 <br />--------------------------- <br />if no alternate TSDF, return to generator <br />15. Special Handling Instructions and Additional Information <br />Waste is RCRA exeopt per 40 cra 261.4(b)(1) exclusion. rear propel RPA tuhen handling hazardous <br />sutterials. Gite:5249 s. Tracy blvd, Tracy CA 95376/ Job N 1483-06200 / SRA Guide 128 , 133 , 1S4 <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, <br />packaged, marked, and labeled/placarded, and are it all respects in proper condition for transport by highway according to applicable international and national government <br />regulations and Arkansas state regulations. <br />If I am a large quantity generator, 1 certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br />practicable and that I have selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human <br />health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management <br />method that is available to me and that I can afford. 7' <br />Printed/Typed Name ^ .°;"''.ril', :r4 ° ,,�• 0x, 1 0 . <br />Signature Month Day Year <br />, o <br />01� r <br />a o <br />T- <br />t7. Transporter 1 Acknowledgement o:'Receipt of Materials I <br />F <br />' <br />=�r,tedTyped Name <br />Signature _ -.�% . -- Month Day Year <br />P <br />O <br />18. T•artsoo-ier 2 Acknowledgement of Receipt of Materials <br />R <br />Prin?=3?r;�d Name <br />Signature Month Day Year <br />T <br />E <br />R <br />19. Dtscreaaricy i-,!Z-.ahon Space <br />F <br />A <br />e <br />t' <br />esexcept as noted in item 19 <br />Month <br />-'="ztor: Cedification of receiRt-';'dous materials covered by ih ss 9^a <br />20. Facility O+:-=' _"ure <br />onrin"�rw:i <br />Form 8700-22 (Rev. 9-88) Previous edition is obsolete. I`Ct�ICQATf1R INITIAI rOPV <br />