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State of Coliforstio-Envitornnental Protection Agency <br />Fo,rn Approved CUP No. 2050-0039 (Expires 9-30-94) See Instructions an back 9*6. Department of Toxic Substances Contra <br />Please Print orN". Form designed for v" on chte (l2-p..Ij&. V Sacramento, California <br />V, <br />it <br />I <br />I <br />tAl <br />00 W WRdE -6EL914f TAB UNE. <br />OTSC 8022A (9/93) <br />EPA 8700--22 Green: TRANSPORTER RETAINS <br />I 'enerator's US EPA ID No. <br />, r <br />• Co <br />Manifest Document No. info rmation in the sSII haded areas <br />is not required by federal low, <br />IjffJiYjZ112:-V2MZ L0 "Al fil U 219 <br />4 3 1 1 1 9 I:Q I 'I <br />3. Gone. rotor's Name and Mailing Address <br />LODI LIQUOR FOOD STORE <br />1225 W. Lockeford St., Loditt CA 95240 <br />4- Generator's Phone ( 209 33 3- 1038 <br />-4 <br />5. Transporter I Company Home US EPA ID wmber <br />NOR CAL OIL C-1 Al DL9i 81214111712,1 <br />5i <br />7. Transporter 2 Company Name 8. US EPA ID Number <br />9- Designated Facility Nome and Site Address 10. US EPA ID Number <br />PRC PATTERSON, INC. <br />13331 N. Hwy 33 <br />iEx M-1 <br />1 1 A ijjijjiai3 iL.Li <br />61617A 21 SM <br />i 11. US DOT De-Aription, (including Proper Shipping Name, Hazard Class, and ID Number) <br />WjILIME <br />--NON-RCRA HAZARDOUS WASTE LIQUID <br />(WATER A OIL) <br />J. Additional Dextiplians for Materfals LisW Above <br />TANK DMOR WAM <br />Eli <br />RIVATE <br />16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment <br />are fully and accurately described above by proper shipping name and are classified, <br />packed, marked, and labeled, and ore in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br />Of I am a large qua" generator, I certify that I have a program in place to reduce <br />the volume and toxicity of waste generated to the degree I have determined to be <br />economically practicable and that I have selected the practicable method of treatment, <br />storage, or disposal currently available to me which minimizes the present and future <br />threat to human health and the envirarmterd; OR. if I am a small quantity generator, <br />I have made a good faith elfort to minimize my waste generation and select the best <br />waste monagem".rjethpd thot:ts jLXodable to row on"' that I n afford. <br />Printed-IT-y—pe—dName 11charif-i Thorpe a-qewt Tfar <br />—� <br />Signature <br />Month Day Year <br />K**# Lodi Liquor Fwd Store <br />0 17 11 16 19 f <br />���er I Acknowledgement of R�Wpf of Materials <br />a <br />Printed/Typed N <br />WORM <br />Me <br />1111- fansporter 2 Acknowledoetnent of Receipt of MAterials <br />*W <br />19Discrepancy Indication Space <br />50 <br />-A�rl <br />woffoll -0 Kai <br />00 W WRdE -6EL914f TAB UNE. <br />OTSC 8022A (9/93) <br />EPA 8700--22 Green: TRANSPORTER RETAINS <br />