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1,ee Arkansas Department of Environmental Quality
<br />i' Hazardous Waste I cion
<br />P.O. Box 8913, Little Rock, AR 72219-8913
<br />Telephone: (501) 682-0833
<br />Please print or type. (Form designed for use on elite (72 -pitch) typ ewriter I
<br />COOP, RE-
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<br />NOTICE_THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE HAZARDOUS STE SHIPMENT. ONCF DPI IVFPFn THP rnl=nrnncnln "1
<br />AP�o�Ok"o. 2050-0039
<br />UNIFORM HAZARDOUS GeneraloYs US EPA ID No. terminal
<br />2. Page t Information an the shaSfe yep$ ypgl
<br />WASTE MANIFEST Document No.
<br />1 01
<br />,� ErNao`uttpipVYR�fC 1��1� t�[/1L111
<br />of
<br />3. Generator's Name and Mailing Add,,sawl
<br />A, ata Manliest
<br />SAX JOAQUIN Cal
<br />AR 5 2
<br />1810 B tU1E1E1'�
<br />-14692
<br />B. State Generator's ID
<br />STO[St1'(1f, CA 95201 ATTR: ALIS( sr M1D5(1X
<br />4. Generator's Phan _
<br />1066
<br />5. Transporter 1 Company Name 6. US EPA ID Number
<br />C. State Transporter's ID
<br />11lillim MW
<br />D. Transited, Phoma
<br />]. Transporter 2Compans� B. US EPA ID Number
<br />T I r.*V s,°n�r .zAve c� K a 9 8
<br />E. State Transport., a ID
<br />H
<br />- s 8 %
<br />F TransporteYs Phone g _
<br />g Designated Facility Name and Site Address 1o. US EPA ID Number
<br />G. State Facira ID
<br />incl INC.
<br />309 AlTRICAX CIPCIE
<br />H. Facility's Phone
<br />1^l. 013114111000, AR 71730
<br />(27618 -717
<br />12. Containers
<br />13. 14.
<br />11. US DOT Description (Including Proper Shipping Name, Hazard Class and ID Number)
<br />Total Unit
<br />G
<br />No.
<br />a
<br />Ylrttaeit L18VTD5, X.O.3., 3, 111111993, Per
<br />I Type Quantity VANel Waste No
<br />E
<br />II, (lab—peyp)r
<br />N
<br />(ecg: 128), (p£, 744520)
<br />R
<br />1
<br />Ii
<br />42 % P
<br />Rb.
<br />NA
<br />A
<br />FLAHMAIIIII S(3.ID5, OBCaCNIC, X.O.S., 4-1, 1051325, Pci II,
<br />T
<br />(Noa£irg Lace, Adhaai.), (ecg: 133), (p£: 744521)
<br />O
<br />NA
<br />R
<br />c
<br />III BESTICXECS LIQUID, FLRlY1BI1R, TOXIC, 3, [1X3021, Fe II,
<br />(By—ttr=iis-, ablaccl.), (acq: 131.), (p£: 744522)
<br />XA
<br />S
<br />q /
<br />0�j1 V `O A
<br />dMAa1R
<br />aF — !1^"�
<br />128)
<br />1510
<br />J. Additional Description far Materials Listed A ve
<br />1LA: 744520111 X 5-5-O R) ) •• 118, 744521( 1,4xii )
<br />K. Emergency Response Information:
<br />•• Ila: 744.522( 5')(PS' Y " CStBt—
<br />III L= 33WCTRRC
<br />(300)535-6053
<br />if no alternate TSDF, return to generator
<br />15. Special Handling Instructions and Additional lmarmation
<br />Xeae pcopete ppe ebm haadlirg hazacdnue laate=iele. Waste ie 3L9A Milimittirt pipe 40 CTR 261.4 (b) (1)
<br />emlmim, nee packed aoaonding to 49 CTR 173.12b. Job41483-04 8 1 4 . site
<br />7350 S. FA 8nidge£ocd St. Sto03rteo, CA. If Mb Guido 128 , 133 , 131
<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 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 />PrintedTyped Name Signature Month Day year
<br />J i d
<br />T
<br />17. Transporter 1 Acknowledgemen of Recei of Materials
<br />R
<br />A
<br />N
<br />Printedrryped Name
<br />Si nature
<br />9 Month Day Year
<br />PW
<br />ill
<br />O
<br />1 B. Transporter 2 Acknowledgement of Receipt Of Matelots
<br />RPr
<br />T
<br />a yped a Signature Month Day Year
<br />E
<br />R
<br />Q a ,i �r
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<br />or xrnd
<br />19. Discrepancy Intl Space
<br />F
<br />A
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<br />20 F ty Owner or Operator: Certifcation of receipt of hazardous materials covered by this manifest except in Item 19.
<br />Y
<br />as noted
<br />not yped No .
<br />Stil a Month Day ye
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<br />FPA
<br />Fn,m .1911_11 IF!— o_not P....u...._ _mss
<br />NOTICE_THE ORIGINAL AND NOT LESS THAN TWO (2) COPIES MUST MOVE WITH THE HAZARDOUS STE SHIPMENT. ONCF DPI IVFPFn THP rnl=nrnncnln "1
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