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�s•'*,.� nl nal lOQa 1-lUpal If ItJI It U I CI IV I I U1 I 1111,111 Lill VUdI I LY <br />n" Hazardous Waste P'-,ision <br />f 1; P.O. Box 8913, Litt, ock, AR 72219-8913 <br />°�•' Telephone: (501) 682-0833 <br />Ploaac print in lypc. (Form designed loruse on elite OP-nifch) bm,,n'b-I <br />GENERATOR INITIAL COPY <br />- <br />UNIFORM HAZARDOUS <br />-11------.1corm <br />1. Generator's US ENUO No. <br />Manifest <br />"P;N., <br />2. Pa e1 <br />9 <br />Approved.. ama No. 2050-0039 <br />Infotmatigo in the shaded areas is not <br />WASTE MANIFEST <br />0 0 1 6 4 f <br />OtiM <br />of <br />required by Federal law. <br />3 Generalor� r"n, 111d M wurg q,funss <br />A. State Manifest Document Number <br />AR -1375223 <br />B. State Generator's ID <br />4. Generator s Phone <br />5. Tdvmi r 1 Co apy Name 6. t) D U�EP$ ID,SJumber., r <br />'"'.'file.'-` e <br />C. State Transporters 10 <br />D. Transporters Phone - <br />7. Trans oder 22 Companyy Name 8. US EP ID ur�tber <br />---ffl ?kii _5X.1 »n -i Tcat!xsprye L•5 9 G 9 8 6� A <br />E. Slate Tren speder's ID <br />J i <br />R. -. <br />F Transponer's Phone - <br />9. Designated Facility Name antl Sita Adtlress 10. US EPA ID Number <br />G. Slate Facility's ID <br />"-' - <br />H. Faalay's Phone <br />11 St 8x f'• 5 3 `i 4 8 A9 <br />1&5{.285$-'PY'a la <br />11. US DOT Description (Including Proper SNpping Name, Hazard Class and ID Number) <br />12. Containers <br />10. <br />Total <br />44 <br />Unit <br />G <br />a , . .. <br />No. <br />Type <br />Quantity <br />WW01 <br />1 <br />Waste No. <br />N <br />.a t <br />E <br />1 <br />O <br />� �� <br />d <br />if <br />c)5355 <br />J. Additional Daaerlie—...... ateri Ir;U letl • n 1. : y,.{. t y <br />K. Emergency Response Information: <br />_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br />if no alternate TSDF, return to generator <br />15SpecialHandling Instructions and Additional Information <br />16. <br />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 <br />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 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, <br />storage, or disposal currently available Td 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 gogdLfaith effort to minimize my <br />wgste generation and select the best waste management <br />method that is available to me and that I can afford. <br />ntetl/ryped Name ,xr ....-:--•-.-�.. <br />SignaNre <br />C y / <br />Z.D`�6 ' /�5 Month Day Year <br />4% <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />N <br />PgptedRyped Name Signlure <br />G <br />f T{ V.IV L �' - A, f Month Day Year <br />p <br />w k .4�i..{:. I <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />Pr ii new yped Name Si na.,a <br />g <br />E <br />Month Day Year <br />R <br />19. Discrepancy indication Space <br />F <br />A <br />C <br />I <br />L <br />T <br />20. Fatality Owner or Opeentoc CeNfcatch o1 receipt of hazardous materials covered by this manifest except as noted in Item 19. <br />y <br />Printed/Typed Name Signature <br />Monts Day Year <br />EPA <br />Form 8700-22 (Rev. 9-88) Previous edition is obsolete. <br />GENERATOR INITIAL COPY <br />