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&N-HAZARDOUS Waste Hauler 1309ument Dally Field Ticket No 815 <br /> . t <br /> GENERATOR DESIGNATED <br /> TSD FACILITY ALTERNATE TDS FACILITY <br /> Name IJ Name s_+ _ Name <br /> EPA # EPA# EPA# <br /> Address (d�� � 1 <br /> Address Address <br /> Order Placed Order Date <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER - OTHER 7L <br /> Weight/Volume Units Container ❑ - Dump Truck �- Tank Truck <br /> This material is nonhazardous because <br /> t)it is a drilling mud containing only the additives listed by the Department in its exemption <br /> letter and contains no significant concentrations of toxic materials from natural sources or <br /> 2)is a sulfur-dioxide scrubber solution from a sodium hydroxise or sodium carbonate oil <br /> field boiler scrubber system and possesses no characteristics that would require its SIGNATURE OF AUTHORIZED AGENT DATE <br /> handling as a hazardous waste <br /> TRANSPORTER <br /> Warren E Gomes Exc , Inc Job No _Ze 3 Pick-Up Date <br /> P O Box 369 /D <br /> Rio Vista, CA 94571 Unit No / IG e OF^Y <br /> (707) 374-2881 <br /> EPA # CAD076557370 <br /> i <br /> TSD FACILITY *hod of Disposal: <br /> e= 3`7 a - Injection Well <br /> Name __ QTY Measured J o - Landfill <br /> Land Treatment <br /> EPA # ❑ - BBL ❑ - TONS ❑ - OTHER ❑ - Surfac ndment <br /> ❑ - Other <br /> SIGNATURE OF AUTHORIZED AGENT DATE <br /> I <br /> TSDF COPY <br />