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e <br /> Waste Hauler Document Daily Field Ticket No. <br /> 45163 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name:_t Name: <br /> Name: <br /> EPA# EPA# <br /> EPA# <br /> Address: Address:-_ ' <br /> Address: <br /> 1 ) <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER ❑ - OTHER <br /> Weight/Volume I Units Container: ❑ - Dump Truck ,�- <br /> 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 DATE <br /> -handling as a hazardous waste. <br /> TRANSPORTER j' <br /> 2- 3� <br /> Warren E. Gomes Exc., Inc. Job No. Pick-Up Dat <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 /> o - Injection Well <br /> Name *- QTY Measured o - Landfill <br /> - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS ❑ - OTHER o -,Surface Impo"nt <br /> T/�) <br /> -[r- Other <br /> —1503 <br /> SIGNATURE mF AUTHORIZ GENT DATE <br /> TSDF TO GENERATOR <br />