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j . <br /> Y <br /> V 54 <br /> NOWHAZARDOUIS <br /> a$t al@C Documellit Daily Field Ticket No.—.. 45479 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS-FACILITY <br /> Name: Name: , . <br /> Name: <br /> `EPA# / EPA# J� - EPA# <br /> Address: ._ ` r Address:;lf /�_l r P" li Lt <br /> Address: <br /> D <br /> - 0 . <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GAS ELL WATER - OTHER / c5K f Vq /CYI <br /> Weight/Volume P?0Units Container: ❑ - Dump Truck, 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 froma sodium hydroxise or sodium carbonate oil <br /> field boiler scrubber system, and'possesses no characteristics that would require its SIGNATURE OF AUTHORIZED AGENT <br /> handling as a hazardous waste. DATE <br /> i <br /> TRANSPORTER <br /> Warren E. Gomes Exc., Inc. Job No. 61cWt i17 1 <br /> 1 Pick- D <br /> P. O. Box 369 <br /> U � ! <br /> Rio Vista, CA 9,4571 Unit No. 0 <br /> (707) 374-2881 IGNATURE OF BUYER <br /> EPA#CAD076557370 <br /> TSD FACILITY_....._ .. Method of Disposal: <br /> ❑ - Injection Well <br /> Name QTY Measured ❑ - Landfill <br /> �- ❑ - Land Treatment <br /> EPA# <br /> ❑ - BBL ❑ - TONS ❑ - OTHER ❑ - Surface I <br /> e-14 moo <br /> ent <br /> ' ❑ - Other <br /> -- <br /> SIG AT OF AUTHORIZED AGENT DATE <br /> TSDF M GENERATOR <br />