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MIKansas uepartment of Environmental Quality ^^ <br /> --—-----.-.--.rte <br /> ~� w Hazardous Waste gWion <br /> " P.O. Box 8913, Littl 2219-8913 ock,AR 7 <br /> r _ i, <br /> Telephone: (501).682-0833 <br /> lease p nt or type. (Form designed for use on elite(12-pitch)typewriter.) <br /> ® <br /> UNIFORM HAZARDOUS .. t.Generator's US EPA ID No. Form Approved.OMB No.2050-0039 <br /> Manifest 2.Pa g 1 Information in the shaded areas is not <br /> WASTE MANIFESTt' n , Dg¢ t required by Federal law. <br /> 3.Generator's Name and Mailing Address of <br /> INT , , 1'ERW. L a INCM <br /> �+ <br /> LODICA 9S24D <br /> 13 S � BfierEttEN'&t!Y �"°a� <br /> 4.Generator's Phone , -f:M ) b <br /> ranse1 �E� ,e' 5 <br /> 5.Tportr Company Name 'S <br /> 6 US EPA ID Number <br /> E"t OWE�4TAL RECt �JEF$Y�?l ", t�Ttatt$pdrtez` f <br /> C fz r5 R' <br /> 7.Transporter 2 Company Name <br /> 8. x �.. <br /> US EPA ID Number E State Trensperter s t0 <br /> 9.Designated Facility Name and Site Address F hanaporter`s Phone <br /> 10. US EPA ID Number G.State Facility's ID <br /> H.Fadiity'sho <br /> , <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class and ID Number) 12•Containers 13. 14 <br /> No. Type Quantity Unit <br /> G a. "VASTE '( t I�N1234 YP MAIM r <br /> E F.ca rata a!I k PGH F+.�.+...�. <br /> N � a <br /> E tai z <br /> R ��A <br /> T IiIVAS7'I:'F -PLE:LI1�1.C1:NNO.S,3, I.:IM% PGj)(AC7d)NE.3 � <br /> O <br /> R <br /> C. <br /> i <br /> d. Att $ <br /> Additional Descri tion for Matenals Listed Above <br /> t$tt K one <br /> ,{ rY Fie <br /> sponse tnforrn1 n - <br /> R,'�. ,P <br /> pp <br /> ifnefalterna�,TSE?F, f�tufn#0 generator KK <br /> 4 <br /> 1 <br /> 15.Special Handling Instructions and Additional Information <br /> r� <sif L 1"C'EI?M€iOIt.3kENNAL RE aiDVLZRY i ,R'Ai ES i'° <br /> 1s. <br /> GE ATOR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above b proper shipping <br /> packaged,marked,and labeled/placarded,tateregultions 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. Y P P name and are classified, , <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;e a 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 /> yped Name <br /> r Signature <br /> Month Day Year <br /> 17.Transporter 1 Acknowledgement of Receipt of Materials `` G- c <br /> A Pn ypad Name i <br /> N g Signature <br /> a «« Ff Month Day Year <br /> O 18.Transporter 2 Acknowledgemgnt of Receipt of Materials <br /> T Printed/Typed Name <br /> r' <br /> E Signature <br /> R Month Day Year <br /> 19.Discrepancy Indication Space (; <br /> F <br /> _1 <br /> f 20.Facility Owner or Operator.Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. <br /> Y Printedfryped Name <br /> Signature <br /> Month Day Year <br /> i <br /> 3A Form 8700-22(Rev.9-88)Previous edition is obsolete. <br /> GENERATOR INITIAI-MEW <br />