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April 2019 Special Waste Proile Disposal Facility: III. Waste Stream Information Waste Proile #: Name of Waste: Process Generating Waste: Type of Waste: Estimated Volume:Volume Type: IV. Representative Sample Certiication Is the representative sample collected to prepare this proile and laboratory analysis, collected in accordance with U.S. EPA 40 CFR 261.20(c) guidelines or equivalent?Yes No No Sample Taken Sample ID Numbers or SDS: Sample Taken Sample Date: I. Generator Information Generator Name: Generator Site Address: City: State ID/Reg No:State Approval/Waste Code:NAICS #: Generator Mailing Address (if diferent) County:State:Zip: City:County:State:Zip: Generator Contact Name: Phone Number:Fax Number: Email: Ext: II. Billing Information Bill To:Contact Name: Billing Address:Email: City:State:Zip:Phone: Physical State:Method of Shipment: Frequency:Disposal Consideration: Page 1 Remember to attach Laboratory Analytical Report (and/or Material Safety Data Sheet) including Chain of Custody and required parameters provided for this proile. Type of Sample Sales Rep #: 4204 Forward Landfill CA Stockton Delta Resort, LLC 14900 W. Highway 12 Lodi San Joaquin California 95242 CAL000420023 ✔38 Commerce Ave. SW, Suite 200 Grand Rapids Kent Michigan 49503 Dominique Maingot dmaingot@northgateholdings.com 561-617-3542 Stockton Delta Resort, LLC Dominique Maingot 38 Commerce Ave. SW, Suite 200 Grand Rapids Michigan 49503 561-617-3542 Burnt Wood Wood debris from a commercial building fire. Fire was suppressed with water. Pollution Control Waste Solid Drum 2 Drums One-time Event (single project)Landfill ✔ ✔ 9/16/20 Burnt wood from building fire Grab Sample Stockton Delta Resort, LLC Burnt Wood