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oa t.. .,ar" r.r,...nsu.ra.rcFrm urwn, yr �rr�vt nrrcnaar +„turzuty <br />Hazardous Waste Di,' ` n <br />P.O. Box 8913, Little AR 72219-8913 <br />Telephone: (501) 682-0833 <br />Please print or type. (Form designed for use on elite (12 -pitch) Noewrifer.) <br />Form doom„oN rl/.AR of <br />9 <br />EPA Form 8700-22 (Rev. 9-88) Previous edition is obsolete. <br />GENERATOR INITIAL COPY <br />UNIFORM HAZARDOUS <br />1.Generator's US EPA ID No. <br />.50.3Document <br />Manifest <br />2. Page 1 <br />V <br />normal in the shaded areas is not <br />CC/I O06 <br />'RN <br />No . <br />requiredbyFederallaw. <br />WASTE MANIFEST <br />of <br />3. Generator's Name and Mailing Address <br />A. State Manifest Document Number <br />r,: <br />AR <br />:'; _ i , _ <br />-1469270 <br />-i .. <br />B. State Generator's ID <br />4. Generator's Phone 1 <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporter's ID <br />H- <br />D. Trensppder's Phone <br />7. Trans pod., 2 Company Name 8 US EPA ID Number <br />E. State Transporter's ID <br />F.TransPorteYs Phone <br />9. Oeslgdaled Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />u t s <br />H. Facility's Phone <br />4 <br />12. Containers <br />13. <br />14. <br />11. US DOT Description (including proper Shipping Name. Feet Class and ID Number) <br />Total <br />Quantity <br />Unit <br />II <br />No. <br />Type <br />pyWol <br />Waste No. <br />E <br />N <br />E <br />R <br />b. <br />A <br />T_ <br />... .. <br />i <br />O <br />R <br />a <br />d. <br />J. Additional Description for Materials Listed Above <br />K. Emergency Response Informafinn: <br />— — — — — — — — — — — — — — — — — — — — — — — — — — <br />if no alternate TSDF, return to generator <br />15. Special Handling Instructions and Additional Information <br />6. <br />GENERATOR'S CERTIFICATION: 1 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 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 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 />Printedrryped Name <br />Signature r <br />Month Day Year <br />T <br />R <br />17. Transporter 1 Acknowledgement of Receipt of Materials <br />A <br />Pr nledRyppd NartJs� � <br />SignaNre tY. Mpn - ay ear <br />IN <br />Z <br />pI6.Transporter2Acknowledgementof <br />Receipt of Materials <br />R <br />T <br />Pdntedrryped Name „",.% ' <br />Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />T <br />20. Facility Owner or Operator: Codification of receipt of hoe dmous materials covered by this manifest except as noted in item 19. <br />Y <br />Printednllp id Name <br />Signature Month Day Year <br />EPA Form 8700-22 (Rev. 9-88) Previous edition is obsolete. <br />GENERATOR INITIAL COPY <br />