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Arkansas Department of Environmental Quality <br /> Hazardous Waste Wion <br /> Y P.O. Box 8913, LittlVIIRock, AR 72219-8913 <br /> .day Telephone: (501) 682-0833 <br /> Please print or type. (Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator's US EPA ID No. Manifest 2.Page 1 i Information in the shaded areas is not <br /> , >� ,• <br /> Document No. required by Federal law. <br /> 11 <br /> WASTE MANIFEST .� % of <br /> " 3.Generator's Name and Mailing Address A,State Manifest DaeurttentNuttlher_r„,. <br /> Gr9: "a' THAMLICTyr :S k � <br /> CA 9,5240 <br /> x 4.Generator's Phone t, -,4 2 n• ?5 0 i'f <br /> a 5.Transporter 1 Company Name 6. US EPA ID Number �C.State Transporter's ID <br /> H c. <br /> Elit,y r es a x r v fir" D.-Trans Transporter's Phone <br /> 7.Transporter 2 Company Name 8. US EPA ID Number E.State Transporter's ID w , <br /> H .fit? •- f'3f S .n' <br /> F.Transporter's Phone <br /> 9.Designated Facility Name and Site Address 10. US EPA ID Number G.State Facility's ID <br /> H.Facility's Phone <br /> 12.Containers 13. 14. <br /> 11.US DOT Description(including Proper Shipping Name,Hazard Class and ID Number) Total Unit f <br /> No. Type Quantity yytNol ,..... -weafeNo;. <br /> C, a. <br /> E A" <br /> l�i�a..�...`T~ k'Ta.:'$:T'�$k�:4�;. sa�.±�wi .l...a..y XiT.1,'J.«�.� �R ��.°..'..1,z•,: ��: ...._. �. :. ., <br /> E <br /> R b. <br /> A MdmIIT'E T'ar�a'THka'1a AC'FTa.&TE, r #JX123, Ery 11 (1*01) $�"��b•;; <br /> T <br /> R F „ t7 �; o <br /> C. <br /> d. <br /> 1 Additional Description for Materials listed Above, K.Emergency Response Information:.; <br /> ,. .y. . <br /> 0 <br /> if°no alternate TSDF=, return to generator. <br /> 15.Special Handling Instructions and Additional Information <br /> ."RGEIN Y k",&LL r-NVT7 0,'3E to <br /> L13:c :EST•.(' E; ,1 "E"!*Y' T':int z.1' €" x t ;; W.o. <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 /> Printedlryped Name Signature Month Day Year <br /> I i <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials <br /> R <br /> A Pdntedrryped Name Signature Month Day Year <br /> N <br /> ; <br /> S <br /> P <br /> O 18.Transporter 2 Acknowledgement of Receipt of Materials <br /> R Printedfryped Name Signature Month Day Year <br /> E <br /> R u� <br /> 19.Discrepancy Indication Space <br /> T 20.Facility Owner or Operator:Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> j^ Y Printed/TypedName Signature Month Day Year <br /> EPA Form 8700-22(Rev.9-88)Previous edition is obsolete. <br /> CZFN5:R®Tn0 INITIA1 P'_(1DV <br />