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�3o �7 <br /> dorm designed for use on elite{12-pitch)typewriter.) Form Approved.OMB No,2050-0039 <br /> Ri]OUS 1.Generator ID Number 2.Page 1 Tf3.Emergency Response Phone 4.Manifest Tracking Number <br /> nuF�sTG61L000273993 800-633 825 <br /> 017090459 J J <br /> �yl�rtlflQda nCI7AODis�iStrlCt GenWesttfghe cf it hpotentthanme!lingaddress) <br /> T5 W Lowell Axe 1775 W Lowell Ave <br /> (racy,CA 209-321-3429 Tracy,CA 95376 <br /> 'lays Phone: <br /> ffynsparteer 1 Company Name U.S.EPA ID Number <br /> Ingenlurrt (Mll¢Itas)C 'k"ERI PHONE-Gust Ila#8766-0002CAR000179747 <br /> y,Tra"Nillard Company Name <br /> Services u,s.EPA ID <br /> B.Des ted FaclliN We aqd 9 Address U.S,EPA ID Number <br /> ,�vance as tiarwees of Indiana LLC INR000127621 <br /> 5625 Old Porter Rd <br /> Portage,IN 46368 <br /> 219-713-6184 <br /> Facility's Phone: <br /> ga 9b.U.S.DGT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No, Type. Quantity WLNoI. <br /> 1- Non-RCRA Hazardous Waste Liquid(SPECIMENS IN FORMALIN) 551 I <br /> p _h- <br /> a 360 l� .. ._.. <br /> . I <br /> Z 2. i <br /> l <br /> 3. I <br /> t <br /> i <br /> t � <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Document D41620 Sales Oder 60744 <br /> 1}Profile#1000130750 DOTERG# <br /> 3X�?S A� <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,t car ily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity gen tor)Is true. <br /> Generators/Offeror' Pill1edfT ped Name Signatur - Month Clay Year <br /> —u 16.International Shipments <br /> ❑Import to U.S, ❑Export from U'S' Pq pentrylex. <br /> Transporter signature(for exports only): Date caving <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 PrintedlTyped Name _ Signature Month Day Year <br /> C <br /> ZTransporter 2 PfintedlTyped Name lySign Month Day Year <br /> o✓ <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ quantity —]Type ❑Residue ❑Parlial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> FacilitysPhone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ), 2. 3. 4. <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous male rials covered by the manifest except as noted In Item 18a <br /> Printed/Typed Name Signature Month Day. Year . <br /> EPA Form 8706-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE.or REgIiIR.ED) <br /> E <br />