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�l <br /> , WAZAF4136US Waste Hauler Document Daily Field Ticket Nc 45037 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: Name: Name: <br /> EPA# 7 �'`� EPA# EPA# <br /> Address: .fcoq' `/o wAAZT � Address: <br /> Address:_ <br /> D X)7A 'A <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL - OTHER <br /> Weight/Volume Units Container: ❑ - Dump Truck [ "- Tank Truck <br /> This material is nonhazardous because: <br /> S _4.. <br /> 1)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. 2 3 ® Pi -Up Date "�' �" <br /> P..O. Box 369 / ®� <br /> Rio Vista, CA 94571 Unit No. <br /> (707) 374-2881 SIGNATURE OF BUYER <br /> EPA#CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> Ts, 464,: ❑ - Injection Well <br /> Name OTY Measured ✓� �' °'" ❑ - Landfill <br /> ❑ - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS E<OTHERS ❑ - Surface Impo e / <br /> 4 <br /> ❑ - Other } ttr'l,.cT"�G' <br /> SIGNATURE OF AUTO ORIZE GENT DATE <br /> R.. <br /> TSDF TO GENERATOR <br />