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rurdi lba5 uvpdrtn rant UI cnvu unfI let tal (,tuaury <br />�1 Hazardous Waste Divi i <br />P.O. Box 8913, Little R(, -K, AR 72219-8913 <br />^ Telephone: (501) 682-0833 <br />Please print or type. (Form designed for use on elite (12-pitch),typewfiter,) <br />Foml Approved. OMB No. 2050-0039 <br />EPA 8) Previous edition is obsolete. - <br />NOTICE: THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE LARDOUS WASTE SHIPMENT. ONCE DELIVERED, THE TREATMENT/ <br />UNIFORM HAZARDOUS <br />t.Generator's US EPA ID No <br />an cat <br />2. Page I <br />Information in the shaded areas is not <br />C A N 1 1 1 0 0 1 0 4 4 <br />6 DpcurpenlNo4 <br />]1 L 66 <br />2 <br />required by Federal law. <br />WASTE MANIFEST <br />of <br />3. Gain orator's Name and Mailing Address <br />A. Slate Manifest Document Number <br />SAN JOLINACOUNTY <br />AR <br />1810 E IL1E'Tcw , <br />-1469264 <br />B. State Generators 10 <br />SS'OcmTciN, CA 95201 ATTN: ALISON HUDSON <br />209)168-3066 (209)468-3066 <br />A. Generator's Phone ) <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Trallspoder's 10 <br />97LRI8 LLC S I 0 0 0 0 9 9 B 8 4 6 <br />H- <br />D. Transporter's Phone (8001649-9720 <br />7 Trinsporter2Cempany Name 8. US EPA ID Number <br />E. State Tranepoder's ID <br />H d0 <br />Smith =Z/t�s 2sNNiposE N N D 9 8 6 3 9 2 1 3 3 <br />F, Transporter's Phone (000) 894-2597 <br />9. Designated Facility Name and Site Address 10, US EPA ID Number <br />G. State Facili" to <br />PMSCO, INC. <br />309 A14MICAN CIRCLE <br />EL DORADO, AR 71730 <br />H. Facility. Phone <br />A A D 0 6 9 7 4 8 1 9 2 <br />- (870) 063-7173 - <br />12. Containers <br />13. <br />la. <br />11. US DOT Description (Including Proper Shipping Name, Hazard Classandi0 Number) <br />Total <br />Quantity <br />Unit <br />1, <br />N. <br />Type <br />WIA/d <br />Waste No. <br />E <br />(=g: 128), (pf: 7445201 <br />IM <br />N <br />E0 <br />R <br />b. PIAN AIK E SOLIDS, �itiIC, N.O.S. , , <br />A <br />(mooting tela, Adheeivee), (ecg: 133), (pf: 744521) <br />M& <br />T <br />° <br />r <br />RDQF-1C <br />2P <br />a , <br />1"4*44w. (1141Nrt'bwt4r lliji f-04. fj4i 1744APPI <br />Ilk <br />9q <br />>, <br />g <br />e- , <br />(pf: 744493) <br />NA <br />T <br />q <br />�( <br />J.Adddionai99X0P)N .�y en b I <br />N3 1 t 1111: 744521( 7( CYl]� <br />K E <br />, ma encY Resarise Information:. <br />r9. P <br />• • i1Ca 744522 ( CJ X �� dry. -s ) •a 11D: 74L4493( X c�Ta <br />Yikvm TUM Xtoo2 (ILC <br />I <br />-(800)838-608! - <br />----------------------- <br />if no alternate TSDF, return to generator <br />15. Special Handling Instructions and Additional Information <br />Tf ee P...P. wN .h.n h,erdlieag tf .ciw. Y.taei.le.ri.ta i. tmmaA marepk P. 40 ®n. 261-o(b) (i) <br />emlwian.Jab 4 1482-(TO17-1,Lts: 7950 S. Illi ffiidgsf�d St, Staakt ,ae. IIA ne peaked aaaatding W 49 <br />CPR 173.12b. if E%i Ouidn 128 , 133 , 131 , 140 <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 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 I have a program in place to reduce the volume and toxicity of wastegenerated 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. <br />Printed(Typed Name <br />SignaWre Month Day Year <br />L. MEI -2 PjT9aT <br />ti O <br />T <br />l7 Transporter 1 Acknowledgement of Receipt of Materials <br />R <br />A <br />beMyped Name <br />Sig Monrh Day Year <br />S <br />/PP <br />U q - <br />P <br />O <br />18. Transporter 2 Acknowledgement of Receipt of Materials <br />R <br />T <br />Printed(Typed Name <br />Signature Month Day Year <br />E1,A <br />I <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />T <br />20. ciLO-perator: Certilicali f receipt <br />zartlous materials coveretl by thls m Re ex pt as noted in It 19. <br />y <br />Pr fe <br />-Month Da /Year <br />EPA 8) Previous edition is obsolete. - <br />NOTICE: THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE LARDOUS WASTE SHIPMENT. ONCE DELIVERED, THE TREATMENT/ <br />