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A 4. H <br /> ` S . aSte auger en# Dalry Field Ticket N•. (�(]f� _ 4 5 4 8 1 <br /> GENERATOR DESIGNATED TSO FACILITY ALTERNATE TDS FACILITY <br /> Name: _5-e C 0/ Name: — Name: <br /> EPA# EPA#, EPA# <br /> t . <br /> Address: Address: 1/ c , T" ,? 1'f g)' Address: <br /> _. ( — — <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATEROTHER 'i ,�'CL1�io <br /> Weight/Volume I o `5 Units Container: ❑ - Dump Truck 211- Tank Truck <br /> This material is nonhazardous beta <br /> 1)itis a drilling mud containin the Additives listed by the Department in its exemption <br /> letter and coKtains no significantconcentrations of toxic materials from natural sources,or <br /> 1)is a sulfur-dioxide scrubber solution from.a sodium hydroxise'br.sodium carbonate oil <br /> field boiler scru¢ber system; and possesses no characteristics that would require its SIGNATURE OF AUTHORIZED AGENT DATE <br /> handling as a hazardous waste: <br /> TRANSPORTER:` ,r. <br /> Warren E. Gomes Exc.,, Inc. Job No. � (I C,. d"�c �"� ��� I Pick-Up D � 03 <br /> R O. Box 369 . . � <br /> Rio Vista, CA' 4571 Unit No. J <br /> 707 374-2881 IGN UYER <br /> EPA#CAD076557376 <br /> 4 <br /> TSD FACILITY Method of Disposal: <br /> ❑ - Injection Well <br /> Name QTY Measured ❑ - Landfill <br /> ❑ - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS ❑ - OTHER ❑ - rface Impoyrtr <br /> t , - Other <br /> � S <br /> SIGNATURE 6 AUTHORMt!)AGENT DATE <br /> TSDF TO GENERATOR <br />