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...,. Arkansas Department of Environmental Duality <br />Hazardous Waste Di '-)n <br />P.O. Box 8913, Little ick, AR 72219-8913 <br />�• Telephone: (501) 682-0833 <br />Please print or type. (Form designed for use on elite (12 -pitch) rypewrhec) <br />I <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 Rev. 9 -BB Previous edition is obsolete.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 />STORAGE/DISPOSAL FACILITY MUST RETURN THIS ORIGINAL COPY TO THE GENERATOR. <br />UNIFORM HAZARDOUS 1. Generators US EPA ID No. <br />Manifest <br />2. Page 1 <br />Information In the shaded areas is not <br />- <br />Document No. <br />i <br />requiretl by Fetloral law. <br />WASTE MANIFEST <br />at } <br />3. Generator's Name and Mailing Address <br />A. Stets ungT <br />[ r <br />.. aw...wr <br />AR_l <br />a C 1 <br />me / ��t <br />B. State Generators ID <br />some"=..CIL Sam MW, ;Aim 1� <br />4. Generators Phase ( - CIII 406-aM.: - <br />5. Transporter Company Name 6. US EPA ID Number <br />C. State Transporters ID H. <br />O. Transporters. Phone > <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />E State Transporters ID " <br />H- <br />. <br />.amen"" _:. ..F. <br />Tg;qorters:Phone <br />9. Designated Facility and Site Address 10. US EPA 10 Number <br />G. State Facility's ID <br />`Name <br />H. Facility's Phone <br />- <br />tKN�N-�t�a . <br />12. Containers <br />13. <br />14, <br />11. US DOT Description (Including Proper Shipping Name, Hazard Gass and ID Number) <br />Total <br />Quantity <br />Unit <br />No. <br />T e <br />yyyyol <br />Waste No. <br />E <br />` <br />�— <br />E <br />U 1 a -M/\ V�— <br />R <br />A <br />Is. <br />T <br />«h■IIMft ....l.ne,. illoap/r ILS" W4 7"W" <br />t o <br />10 655 <br />EL <br />0 <br />w <br />R <br />�•1r1r11�12ap, rrar/s/. +s>oa, 31 Nam, w t:. <br />MP1Kel/1. lift11.r.r. tow 21q. Ilver lddBm <br />=L <br />it r2R =IIll1I0 WAOMM. 1,. mum, M1 22. " "! ftu" • <br />MoP 1�, rR■ talgqirlis <br />�► <br />ie <br />« <br />ditto f rials Listed Above <br />K. Emergency Response Information: <br />__• ------------------------ <br />if no alternate TSDF, return to generator 153(3 <br />15. Special Handling Imdrum ions and Additional Information <br />re +/eegelwlo w/ i■n W■o1wm ■mbeeiels. IfteM is 2rL 4mmipc 11 N CM 20. tp W <br />48■1nMn. we MSr 6e060da" to Y Mi 113.211. 216 MM3- 11fat 71111111,1111 e. <br />2i rf}[M r. Met6ta a KIK / miiii e mi 2M . It" . 2M <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 in 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, I certiy 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 avad <br />e which minimizes the present and future threat to human <br />health and the environment: OR, it I am a small quantity generator, I have made a 90 it to mlmmlze my <br />wa a generation and select the best waste management <br />method that is available to me and that I can afford. 17 <br />'M drryped Name <br />Month Day Year <br />I <br />T <br />R <br />17. Transporter I Acknowledgement of Receipt of Materials <br />3 <br />drryped Name ^D� Signature <br />/!) <br />©Mont Day Year <br />fC�J <br />A <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Pdntedrryped Name <br />4130"Y <br />Signature <br />Month Day Year <br />// /' <br />A <br />A1LAO 1( 6- <br />[N( L2i— O Pl O <br />19. Discrepancy Adication Space -- <br />F <br />A <br />C <br />I <br />L <br />T20. <br />Facility Own r r Operator. Ce 1ficatkmNoelpt of hazardous materials covered by this man'rfest ex as noted In item <br />Y <br />Prtntedri me <br />Signature <br />_Month Day Ygar <br />EPA Form 8700-22 Rev. 9 -BB 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 />STORAGE/DISPOSAL FACILITY MUST RETURN THIS ORIGINAL COPY TO THE GENERATOR. <br />