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w w <br /> — AZ US Waste Hauler Document Daily Field Ticket No. J � 45676 <br /> 1 <br /> GENERATOR DESIGNATED TSD FA ILITY ALTERNATE TDS FACILITY <br /> Name: A�� Name: Name: <br /> EPA# EPA# _ EPA# <br /> Address: <br /> Address: ` w' Address: <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL TEROTHER 6ei?Se&1oy(e- <br /> Weight/Volume 110 9131S Units Container: ❑ - Dump Truck - ank 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 suffur-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 �6 6,-Wt9fJ>;1e Pick-Up Date <br /> P. O. Box 369 <br /> Rio Vista, CA 94571 Unit No. <br /> (707) 374-2581 SIGNATURE OF ER <br /> EPA#CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> -' ❑ - Injection Well <br /> Name QTY Measured ❑ - Landfill <br /> ❑ - Land Treatment <br /> EPA# ❑ - BBL 0 - TONS 0 - OTHER ❑ - Surface Imur�d�nent <br /> p -Other //" � <br /> A/v 9 <br /> SIGNATURE OF AUTHORIZED AGENT 16ATCI <br /> TSDF TO GENERATOR <br />