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Hazardous Waste D' 'on <br />P.O. Box 8913, Little ..ck, AR 72219-8913 <br />Telephone: (501) 682-0833 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter,) <br />Form Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev. 9-88) Previous edition is obsolete. <br />GENERATOR INITIAL COPY <br />UNIFORM HAZARDOUS <br />nerators US EPA ID No. - <br />Manifest <br />2. Page 1 Information in the shouted areas Is not <br />.. , <br />Document No. <br />required by Federal law. <br />WASTE MANIFEST <br />- <br />of <br />3. Generators Name antl Mailing Address <br />A. State Manifest Document Number <br />AR- 1155586 <br />B. State Generator's ID <br />4. Generators Phone <br />5. Transporter 1 Company Name 6. US EPA ID Number <br />C. State Transporters ID <br />H- <br />D.Trensporter's Phone <br />7. Transporter 2 Company Name 8. US EPA ID Numbar <br />E State Trensponer's ID <br />H- <br />F. Transporters Phone <br />9. Designated! Facility Name and Site Address 10. US EPA ID Number <br />G. State Facility's ID <br />H. Facilitys Phone <br />12. Containers <br />13. <br />14. <br />11. US DOT Description (Including proper Shipping Name, Hazard Class and ID Number) <br />Total <br />Ouanlity <br />Unit <br />1. <br />No. <br />Type <br />wvvol <br />Waste No. <br />G <br />a. <br />E <br />N <br />E <br />R <br />b. <br />A <br />T <br />O <br />R <br />c. <br />d. <br />J. Additional Description for Materials Listed Above <br />K. E..rg.F!7y Response Information: <br />if no alternate TSDF, return to generator <br />15. Special Handling 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 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 efforttto 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 />Signature Month Day Year <br />T <br />17. Transpbniir I Acknowlod gnarl[ of Receipt of Materials <br />R <br />A <br />Pdrrtedrrypetl Name <br />Signature Month Day Year <br />N <br />S <br />P <br />O <br />18. Transporter 2 AcknoMedgement of Receipt of Materials <br />R <br />T <br />PlintedRyped Name <br />Signature Month Day Year <br />E <br />R <br />19. Discrepancy Indication Space <br />F <br />A <br />C <br />I <br />L <br />7 <br />20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manliest except as noted in Item 19. <br />Y <br />Prin[edrTypetl Name <br />Signature Month Day Year <br />EPA Form 8700-22 (Rev. 9-88) Previous edition is obsolete. <br />GENERATOR INITIAL COPY <br />