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ar me <br /> m lir r r r mi Mr r r r �3 �rrl <br /> y <br /> oa <br /> NON-HAZARDOUS Waste Hauler Document Dally Field ricket No - { <br /> g <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name r �� Na'ner- C Name <br /> a <br /> EPA# EPl4# <br /> EPA# <br /> Address s Address A -V'r O 2 7 K c� <br /> Address <br /> Order Placed — Order Date <br /> iIViST� ❑ - DRILLING MUD ❑ - GASWELL WATER OTHER— 2c,4 tr` A C r <br /> WelghWdiume Units _6-5L<. Container- ❑ - Dump Truck Ja, Tank Truck <br /> ` Tff��is matenal is onh&srdous because, <br /> ..1titrlFiigmudtbntaining ons the additives listed by the Department in Its exemption <br /> letter and contains no significant Goncerltrations of toxic materials from natural sources or , <br /> 2)id a sulfur-dioxide scrubber solution from a sodium hydroxise or sodium carbonate oil —- <br /> field boiler !!Grubber system, and po3sess9s no characteristics that would require Its SIGNATURE OF AUTHORIZED AGENT <br /> handling 04 <br /> g hazardous waste ' DATE <br /> TA NSPORTER <br /> Warren E Gomes Exc , Inc. blob No Pick-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 /> t <br /> TSD FACILITY ir � Method Qt Disposal: <br /> Name ` QTY Measured __ G -� ° - Injection Well <br /> Q - Landfill <br /> EPA #_ <br /> ❑ - BBL O - TONS ~S]z OTHER ❑ - Surface Ii nmeat <br /> ' ' 11 - Other <br /> —I (// -) <br /> SIGNATt1RE OFv AUTHORIZED AGENT DATE <br /> e <br /> s <br /> TSDF TO GENERATOR <br />