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I
<br />Arkansas Department of Environmental Quality
<br />Hazardous Waste Div' i
<br />P.O. Box 8913, Little ;k, AR 72219-8913
<br />Telephone: (501) 682-0833
<br />Pkxa -- print 4r type. (Farm designed for Use on elite (12 -pitch] lypewrifer.l
<br />I
<br />Fomr Approved. OMB No. 2050-0039
<br />EPA Form 8700.22 Rev. 9-88) Previous edition Is obsolete.
<br />NOTICE: THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE HAZARDOUS WASTE SHIPMENT. ONCE DELIVERED, THE TREATMENT/
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<br />UNIFORM HAZARDOUS 1. Generator's US EPA ID ell
<br />Manhest
<br />2, Page 1
<br />Infomiafion in the shaded areas Is not
<br />Document Na.
<br />required by Federal law.
<br />WASTE MANIFEST
<br />of
<br />3. Generators Name and Melling Address
<br />A State�o'iT
<br />Qocyment tiff
<br />am J�a�T
<br />AR
<br />546175
<br />11810 a1 lookom
<br />B. State Generators ID
<br />ae6las, a ""I SO=, ALLD= 1910011
<br />4. Generators Phone ( 46III-314)• 4209141111111-30"
<br />5. Transporter 1 Company Name 6. US EPA ID Number
<br />C. State Transporters ID H
<br />D. Transporters Phone
<br />7. Transporter 2 Company Name e, US EPA M Number
<br />E. State Transporters ID
<br />H -
<br />mom asebm I IR 11 IN A Ij A ' • 11 1 ' s
<br />R Transporters Phone
<br />9. Designated Facility Name and Site Address 10. US EPA ID Number
<br />G. Slate Fac"hy. ID
<br />TERM, LSC
<br />300 ami
<br />H. Facility's Phone
<br />8L OM6, M 71730
<br />aaoIII i•t••1•2
<br />nn
<br />12. Containers
<br />13.
<br />14.
<br />11. US DOT Desorption (Including Planar Shipping Name, Hazard Class and 10 Number)
<br />Total
<br />Duanti
<br />Unit
<br />1.
<br />No.
<br />Type
<br />WWaI
<br />Waste No.
<br />E
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<br />J. Additional a cription Sor Mat ]ria Lis /,b1 74131 7A
<br />1, 74W2
<br />K. Emergency Response Information:
<br />.• LSD, 788636 / (711 1
<br />ills �rr6
<br />1M•Ifi�-•Ma
<br />---------------------------
<br />if no alternate TSDF, return to generator j7j j$
<br />15. Special Handling Instructions and Additional Information
<br />>•6e agpelillpWb 960 libm hdlitg bsuardsitso rbaile. 961 is bu coil pe 60 tat 261.494 411
<br />WMInifilluIR. Me •oriw6 sooacdi" to Y CM 173. ifb. Job •1Y3-06826 fib, 7.60 6wat8 Sk 111cidghte" at.
<br />ar set.. a1 SIM. / r swift 32• , 133 , 131
<br />1a. 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 in all respects in proper condition for transport by highway according to applicable international and national government
<br />regulations and Arkansas state regulations.
<br />It I am a large quantity generator, I 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 ch minimizes the present and future threat to human
<br />health and the environment; OR, 8 I am a small quantity generator, I have made a go a to!Z ze my waste gene rid select the best waste management
<br />method that is available to me and that I can afford.
<br />PrinhIMMM�
<br />Si azure dforf $Dat eas
<br />T
<br />R
<br />17. Transporter t Acknowledgement of Receipt of Materials
<br />A
<br />Pdnted(Typed Name
<br />Signature Monts Day Year
<br />"s
<br />t(Vk
<br />21
<br />P
<br />0
<br />18. Transporter 2 Acknowledgement of Receipt of Materials
<br />RPrinled/Typed
<br />Name
<br />Signature Month Day Yale,
<br />E
<br />R
<br />19. Discrepancy Indication Space
<br />F
<br />A
<br />C
<br />1
<br />L
<br />120.
<br />T
<br />Facility Owner or Operato - fification of rac n ous materials covered by this manifest except n ed in item 19.
<br />Y
<br />PrintedrTyped Name
<br />Signature Month Day year
<br />Cb
<br />EPA Form 8700.22 Rev. 9-88) Previous edition Is obsolete.
<br />NOTICE: THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE HAZARDOUS WASTE SHIPMENT. ONCE DELIVERED, THE TREATMENT/
<br />CTr1RAf:F/nISPf1SAl FAf:II T/ MIICT RFTIIRN THIO r1RIGINAI (:(1PV TG THF l:FNFRATGR
<br />
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