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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1. Generator ID Number 2. 1c lot 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST C Lr1104-95595 844.131_2460 014789130 JJ 5, Generators Name and Mailing Address Generator's Site Address (If dill mantthan mailing address) ARAVIARK 71779 S. LONGE ST STfia-Mr4, GA 215290 Geneatats Phonex"n�"�''234'01��' 6. Transporter 1 Company Name - U.S. EPA ID Number PHILIP1�EST IP1Di iSTRLzxL SERVICES' CARE�Ytiir527 1. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number WASTE falr',NAGE7diENT KETfLEMgPd L3D!DFIL CARX10c=Ei17 35251 OLD SKYLINE ROAD '...... KML E10A..P11 CA 93239 '.,.. Facilitys Phone: ea. gb, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit and Packing Group if an 13. Waste Codes HM 9 P ( Y)) Na. Type Quantity Wf.Nol. 1. U40N RCIRA HAZARDOUS WASTE, SOLID 06i CFA 15 � 491 0 ( LAUNDRY SLULIGE: - ---- 0 3. iL tit ...,,_. _..--._1�.�..._ d [ 4. ) i i 14. Special Handling insbuctions andAddftionel Information - LINES : PROFILE: CiA60SW2 LAUNDRY SLUDGE ERGiM71 WrEAP PROTECTIVE GLO11-HPIG A140 EYEWEAR. '....... T e ;h W '56D r 1; HLU�Wro 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare thallhe contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeledlplacarded, and are in all respects In properwrdition for transport according to applicable internationalism] national governmental regulations. if export shipment and l am the Primary Exporter, I mortify that the contents of this consignment conform to the terms of the allachad EPAAcknowledgment of Consent. I certify that the waste minimization statement identified In 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (ifI am a small quantity generator) Is true. Ge r tat fOfierots Printedff ped Name Sign a Month Oa Year 1 —+ 16. International Shipments j--. Impart to U.S. ❑ Exportfrom U.S. Portofenfrylexit: Transporter signature (for exports only): Date leaving U.S.: W 17. TanspoderAcknowledgment of Receipt of Materials Transporter 1 Pdnledflyped Name Signature Month Day Year o H q v O��G 1 6 6 Transporter rinted/fyped Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑ Residue 1 ❑ Full Rejection El Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPAID Number J U LL Facility's Phone: eo 18c. Signature of Alternate Facility (or Generator) Month Day Year z N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2, 3. 4. 20. Designated Facility Owneror Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in hemi a PimtedlTyped Name Signature Man D y Year EPA Form 8700-22 (Rev. 3-05) Previous Millons are obtrolete, PDESIGNATE® FA61LI V TO DESTINATIONSTATE (IF REQU113E®)