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,. . N—HAZARDOUS Waste Hauler DocumentDaily Field Ticket No. 41) 45162 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: _ ' Name: Name: <br /> EPA# EPA# EPA# <br /> Address: W Address: � ✓ rs Address: <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL ATEI� ❑ - OTHER <br /> Weight/Volume 12,2 Units /o Container: ❑ - Dump Truck H - 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 - <br /> Warren <br /> Warren E. Gomes Exc., Inc. Job No.. 34 as Pick-Up Date <br /> P.O. Box 369 �� X"'4) "'~(707') 374-2881 OF RIO VI$ta, Ci/4 94571 Unit NO. SIGNATURE OF BUYER <br /> EPA#,CAD076557370 <br /> a:x <br /> +:4 <br /> TSD FACILITY Method of Disposal: <br /> . - 0 - Injection Well <br /> Name - - QTY Measured � � U 0 - Landfill <br /> 0 - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS ❑ - OTHER 0 -,Surface Imw-ent <br /> Other // - <br /> 0..3 <br /> SIGNATURE OF a, THORIZEQ GENT DATE <br /> I <br /> TSDF TO GENERATOR <br />