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NON-HAZARDOUS <br />WASTE MANIFEST <br />- , , ,, .... • , <br />1. Generator ID Number <br />C C 03119611 <br />2 Page 1of <br />1 <br />3. Emergency Response Phone <br />800-255-3924 <br />4. Waite Tracking Number <br />05132021-C <br />5. Generators Name and Mailing Address <br />City of Ripon <br />259 N Wilma Avenue <br />209-599-218 Ripon CA 95366 <br />Generators Phone: <br />Generators Site Address (if different than malting address) <br />W Colony and Goodwin Drive <br />Ripon, CA 95366 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />Independence Environmental Services. LLC CAR000306548 <br />Transporter 2 Company Name U.S. EPA ID Number <br />Facil <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />Yolo County Central1F11T .ill ll CAL000798887 <br />44090 Road 28H <br />530-666-8775 Woodland, CA 95776 <br />s Phone: <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />Hm and Packing Group (if any)) No. Type Quantity Wtftlol. <br />cc <br />0 <br />g <br />1. <br />Non-Hazardous Waste Water .1.1 I'I!I G <br />Lai <br />z u..t <br />0 <br />2. <br />3. <br />4. <br />Special Handling Instructions and Additional Information <br />GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste <br />Cl <br />Ge rator Off es Printed/Typed Name OE 0 Signatu 01?0 Month Day Year <br />4•T A.0 12 :pa, CA'T 6-E 11:t ak..... . 1 0C-IIZ 1.24 <br />-.1 15. Intemationa ShArt.-s — import to U.S. Export from U.S. Port of entryfexit F— <br />-• Transporter signature (for exports only): Date leaving U.S.: <br />Ce 16. Transporter Acknowledgment of Receipt of Matenals Lu i—erler 1 Printed/Typed Name Signature Month Day Year <br />Ce <br />0 0_ ili Ay. I os-- a 7-4 cn z Transporter 2 Pont yped me Signature Month Day Year <br />g I I I I <br />17. Discrepancy <br />Discrepancy Indication Space Quantity DType Residue Partial Rejection LI Full Rejection <br />i <br />Manifest Reference Number <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />F..3 <br />< u. Facility's Phone: I <br />el 17c. Signature of Alternate Facility (or Generator) <br />i— < z <br />Month Day Year <br />I I 0 if) w cl <br />18. Designated Facility Owner or Operator Certification of receipt of materials co by the manifest except as noted in Item a <br />Pnntedayped Name(' i I <br />•rql 1 C,N,e... L il K <br />I Signature Month Day Year <br />I C 1(1 12A <br />ffi <br />Please print or type. (Form designed for use on elite 1 - <br /> extc,k 4-- om <br />6 NI-1M-0-C-11 <br />1-DESIGNATED FACILITY TO DESTINATION