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* . rN, " <br /> a <br /> i <br /> N-HZWaste Hauler a Daily Field Ticket No. °� 5155 <br /> GENERATOR DESIGNATED TSDFACILITY ALTERNATE TDS FACILITY <br /> Name: Name: Name: <br /> EPA# EPA# EPA# <br /> Address: "� t j Address: ' p4_PorL� � Ci Address: <br /> Order Placed: Order Date: , <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER ❑ - OTHER Z dv9 <br /> Wei ht/Volume Units ;1 Container: ❑ - Dump 9 � � �. p Truck kl - Tank Truck <br /> This material is nonhazardous because: <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 ,frte <br /> Warren E. Gomes Exc., Inc. Job No. Pick-Up Date <br /> P. O. Box 369 <br /> Rio Vista, CA 94571 Unit No. ! <br /> (707).374-28$1 SIGNATURE Of BUYER <br /> EPA#CAD076557370 <br /> TSD FACILITY <br /> Method of Disposal: <br /> 0 C) / ,r Injection Well <br /> Name QTY Measured ( (� ❑ - Landfill <br /> iv o - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS OTHER ❑ - Surface Impoundment <br /> - Other <br /> SIGNATUI <br /> ff Of AUTHORIZED ACtr DATE <br /> I' <br /> TSDF TO GENERATOR <br />