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_� . (�� ,Wil, >•-°� <br /> Please printbr"b.-(Form-desig edforuse pitch)lypewrilqr.) Form Approved.OMS No.2050039 <br /> Page I of 3.Emergency Response Phone 4.MantfatTratkir <br /> WASTE MANIFE! I sw-wmm- 'I <br /> T 017090459 JJK <br /> UNIFORM HAZARDOUS I-Gana for ID Number Tracking Humber <br /> 5.Geri 8ALOW27399,1 'pm — <br /> Gene tors d`ii�il ,%Wnt than adling address) <br /> 1075 W Lovval Aw <br /> 1775 W Lo Z Aw <br /> Tracy,CA Tracy,CA 95370 <br /> 2 <br /> Generalofs Phone. <br /> (I.Transpo rjpM ompan�n <br /> U.S.EPA ID Number <br /> P ER?PHONE-Oust ID#8-f66-0W26*`) CAROW1 79747 <br /> 7-15ralir <br /> rF <br /> 'Waml <br /> U.S,EPAIDNtrmber <br /> WiVtM of Indiana LL(; U.S.EPA ID Number <br /> 5625 Old Poe"Rd IN0'127621 <br /> Portage,IN 46398 <br /> 219-MwM84 <br /> FacilWs Phone: <br /> 9a, 9b.U.S.00TOncription findudIng Proper Shipping Name,Hazard Class,ID Number, 10.Conte vers 11.Total 12,Unit <br /> HM andPatWrgGraup(Ifany)) 13,Waste Codes <br /> NO. Type Ovantity WIX31. <br /> 1.Norwcto Hq Waste Liquid(SPECIMEN,9 IN FORMALIN) <br /> -2,660 <br /> LLI <br /> ED <br /> 4, <br /> 14.Sped.]Handling tnslwvticns and AddjdmpJ Infouns <br /> IbOW6110rit D41V() I Wer 60744 <br /> I)PO&MG00130750 DOTERG9 <br /> p- <br /> 15, GENERATOWSIOFFEROR!SCERTIFICATION:1 hereby dedafe that the contents of this consignment are fully and accurately clasalbed allove by the proper shipping name,and are dassIfled,packaged, <br /> marked and lebelaplacaided,and are ln allfeapec(s In proper condition fortnanspDrta=69 to applicable Inlemallonal and na6flal goivemmentat regulations.Ifexport shipment anal am She Pdmary <br /> Exporter,I certify That the contents ol'this consignment conform to the terms of the attached 9PAAcki owIedgmentofConmt, <br /> certify thatthe waste mintnifMion statement idatiffiled in 40 CFR Z27(a)of I am afargatIdantityguirator)Dr(b)(91 am asmall quantity ge"tor)is we. <br /> Gonarator' 0ff;PPteqy*Name signal Month Day Year <br /> 76 <br /> InternaVonal ShlfpmenW <br /> FlImport tou.s. ❑Ev"t from U.S. P rt entry/ <br /> 1payIna <br /> IT.TranspcderAcknovkdgnienlo(Recdptofmllodals <br /> Transporter I Pdrited(ryped Name %nalu Month Day, Year <br /> 0 <br /> IL <br /> c6i 6 7 <br /> Transporter-?Vntedrilyped Name Sign <br /> Month Day Year <br /> fi Sri f <br /> 18.D)screpancy <br /> 18a.Disacpancy Indication Space ❑ <br /> O."fity ❑Type. D R%ldueLIPa,01 Rdjaclion El Full Rejection <br /> Manifest Referenca Number, <br /> 18b.Aftemate 1`06MY(or Generator) <br /> U.S.EPA 10 Number <br /> to <br /> W Fadli?ys Plionw. <br /> 18C.819naG of Alternate Facility(or Generator) Month Day Year <br /> 19.Haz6dous Waste Re <br /> .part ManagementMothod Codes @,e.,codes for hazardous waste treatment,41spa g s <br /> .�al,and repVC In11 stems y <br /> 2 4,- <br /> 20.Designated Facility Owner or Opersto;--Certificakon of recelpt at hazardous male6ls covered by the manifest axoept as noted In I efn 18a <br /> POMW7 Name Signature Montt Day Yearl <br /> EP Form 8700-22(Rev.3.05) Peqvlous adiflons are obsolete, <br /> DESIGNATED FACILITY TO GENERATOR <br />