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a0111111 - im � t s m M W IM ow "M W iM No *mor_ 1W <br /> NON-HAZARDOUS Waste Hauler Document Dally Field Ticket No _41em - 4955633 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Narne - - - - Name ::F ..t. Name- - - - <br /> EPA # EPA # EPA # <br /> Address Address { f Address <br /> .ate <br /> =&0t4l CA <br /> Order Placed _ Order Date <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER ® - OTHERWIX99. <br /> ' I , Weight/Volume — Lfl0 Units La . Z - Container ❑ - Dump Truck 19- Tank Truck <br /> OL <br /> Thi materiel Is nonhazardous because <br /> 11 rt Is a drilling mud containing only the additives listed by the Department In its exemption <br /> letter and contains no significant concentrations of toxic materiels from natural sources or <br /> 2) I A sulfur dioxide scrubber solution from a sodium hydroxlse or sodium 6arbonate oil <br /> 11e1 rboiler scrubber system and possesses no characteristics that would require Its SIGNATURE Of AUTHORIZED AGENT DATE <br /> h sng as a hazardous waste <br /> TRANSPORTER <br /> Warren E Gomes Exe Inc Job No �� -�Ir Ccoz__ ,q.�/ Pt k Up ale <br /> A-- <br /> P O Box 369 <br /> Rio Vista, CA 94571 Unit No lim <br /> (707) 374-2881 SIGNATURE OF BUYER <br /> EPA # CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> _ 0 - Injection Well <br /> 0 - Landfill <br /> Name ��,�.�, QTY Measured Z' � ���� - � C _ Land Treatment <br /> EPA # 0 - 68L ❑ - TONS ❑ - OTHER 0 - Surface ImpotuTd nt <br /> 1 0 - Other ## <br /> 5IGNATURE OF AUTHORIZED AGENT DATE {j <br /> f <br /> - TSDF TO GENERATOR <br />