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s � � <br /> NON-HAI• ..k <br /> -HAZA este 1U'eP en Daily Field Ticket No. q121 <br /> GENERATOR J DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: Name:Tlq /'12 <br /> Name: <br /> EPA.,# EPA# <br /> EPA# <br /> Address; # f Address: 0 / /40/1 A <br /> Address: <br /> Isf C k <br /> 4 <br /> Order Placed': Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER OTHER 1_ f1C4 tfi <br /> Weight/Volume Z 3 Units Container: ❑ - Dump Truck 04Tank 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 itsSIGNATURE OF AUTHORIZED AGENT <br /> handling as a hazardous waste. DATE <br /> M <br /> P®RTER <br /> ` <br /> ren . Gomes Exc., Inc. Job No.� 0 rA �'tr,'�' � r�c��J-1/ pick-Up Da <br /> P O. Box 369 / <br /> Rio Vista, CA 94571 Unit No. Z <br /> (707) 374-2881 SIGN A F BUYER <br /> EPA#CAD076557370 <br /> TSD FACILITY Method of Disposal• <br /> 0 - Injection Well <br /> Name QTY Measured _2 o - Landfill <br /> 13 - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS @'=1,OTHER ❑ - Surface Impq �nt <br /> � <br /> Other <br /> SIGNATOR OF /�AUTHORIZED AGENT fs <br /> DATE <br /> TSDF TO GENERATOR <br />