|
e• •n Miff uepalunera or CNVlfonrnernal ldualny
<br />Hazardous Waste Di%,: -Ion
<br />P.O. Box 8913, Little i AR 72219-8913
<br />-Telephone: (501) 682-0833
<br />Please print or type. (Form designed /or use on elite o2 -Ditch) Noewdtec)
<br />Fnmr n,.n..,,,aa ns,o u,. oncn_nnm
<br />UNIFORM HAZARDOUS 1. Generators US EPA ID No.
<br />Manifest
<br />2. Page 1
<br />Information in the shaded areas is not
<br />Document No.
<br />required by Federal law.
<br />WASTE MANIFEST
<br />9
<br />fl
<br />I Gerremlor's Name and Mailing Address
<br />A. State Manifest Document Number
<br />amJawg
<br />AR -1495828
<br />1810 E HRZrLTON
<br />B. State Generators ID
<br />STO(ZTOi, G 96201 A1R7: ALISON 161DSON
<br />4. Generators Phone(209) 468-3046 (209) 468-3066
<br />5. Transporter 1 Company Name 6. US EPA ID Number
<br />C. State Transporters ID H
<br />9lwI8 LLC 1111 0 0 9 9. 9 9 6
<br />D. Transporters no
<br />7. Transporter 2 Company Name 8. US EPA ID Number
<br />E. State Transporters ID
<br />H
<br />Jill stat, lsiYpme:t >t '111 9 6 3 9 4 1 3 3
<br />F. Transporters Phone
<br />7
<br />9. Desgnaletl Facility Name and Site Address 10. US EPA 10 Number
<br />G. State facility's ID
<br />PXS fO, IBC.
<br />309 AMMICAN CIRCIL
<br />H. Facility's Phone
<br />EL Dd1ADO, AR 71730
<br />: P 0 6 9 7 s
<br />(970)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 />QuantityNo.
<br />Unit
<br />I.
<br />Type
<br />WWOI
<br />Waste No.
<br />G
<br />a.FLANWAMM LIQUIDS, R.O.S., 3, 0101993, 80 II, (lab-peakl,
<br />E
<br />(erg: 128), (pf: 74{520)
<br />a
<br />N
<br />EPt
<br />a
<br />A
<br />A
<br />b_PLAtRi15IE SOLIDS, 08AWIC, N.O.S., 4.1, 1101325, 8B II,
<br />T
<br />(Roofing •--e, Adhesivaa). (e* -`8: 133), (p£: 744521)
<br />1Qk
<br />D
<br />_
<br />-1,7
<br />P
<br />fl
<br />a
<br />it w) -1.7-o5
<br />(
<br />C.O'k5xvx..ls Ca.'o-w;ocl. Uwn-a'; 1,A-�,-o�i�j(4,.L+ed Qe•,,a,j�
<br />m.
<br />iafO I�y�a&
<br />=
<br />1 I =
<br />m
<br />J. Additjm I�Scn)tVtetEkWUstedti+jb 50 I 1,e 11Br 744521( % )C -
<br />//�`.��J4.�
<br />K. Emergency Response Information:
<br />ice-•-+-8j.�:�EKKJJ
<br />I •• 11111, 744526( %JxNIB �.FD!
<br />L� Dllto!`AC
<br />-
<br />tsoo>a33-spina
<br />----------------------- I^
<br />if no alternate TSDF, return to generator Dl%
<br />15. Special Handling Instructions and Additional Information
<br />Avec appcopie PPL when handling taaerdcue eateadialef. Siesta in BCIAA ens•pt pac 40 CFR 261.4(b)(1)
<br />aaalum-- . � wain packed aaaocding tro 49 CER 173.12b. JobR1483-CrJJ3!Qite:
<br />7850 S M BcidgeEoed St.
<br />Stockton CA 95206 /610 Official 128 , 133 , JJr'Jib
<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 Iabelecilplacarded, and are in all respects in proper condition for transport by highway according to applicable intemational and national government
<br />regulations and Arkansas state regulations.
<br />If I am a large quantity generator, I certify that 1 have a program in place to reduce the volume and toxicity o e generated to the degree I earmined to be economically
<br />practicable and that I have selected the practicable method of treatment, storage, or d' cur ntly le to Me ich mini a present and future threat to human
<br />health and the environment; OR, it 1 am a small quantity generator, have mad good faith ort t minimize my w edition and select the best waste management
<br />method that is available to me and that I can afford. -
<br />' t yped NameSig lure
<br />Month Day Year
<br />Or
<br />�l ti
<br />T
<br />R
<br />17. Toa ammo it I Acknowledgement of Receipt of Materiels
<br />A
<br />Printetlrryped Name
<br />Siglure
<br />Month Day Year
<br />N
<br />S
<br />T o je
<br />1AD t5'
<br />P
<br />O
<br />16. Transporter 2 Acknowledg.mpecsam of Materiels
<br />R
<br />T
<br />e
<br />'net a
<br />lesions Day Year
<br />. DmFllel icafio
<br />F
<br />A
<br />C
<br />L
<br />17
<br />1
<br />T
<br />20. Facility Owner or Operator. Certification of receipt of hazardous materials covered by this man4V except as noted in item 19.
<br />V
<br />intimi Typed Name
<br />nw
<br />Signature
<br />Month Day Yea
<br />EP
<br />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 />STORAGEIDISPOSAL FACILITY MUST RETURN THIS ORIGINAL COPY TO THE GENERATOR.
<br />
|