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��tt��11w' w 5 �. CC r� <br /> N.O.N- AZA D Waste aul r Document Daily Field Ticket No. •'� "''� 45168 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: Name: _ Name: <br /> EPA# EPA# <br /> EPA# <br /> Address: �° $ Address: 1165 C /� 41 W Address: <br /> M Vl?i 4 <br /> Ordei Placed: Order Date: <br /> WASTE 11 - DRILLING MUD ❑ - GASWELL WATER 5?- OTHER <br /> Weight/Volume 2 a Units 1144 Container: ❑ - Dump Truck ,['fl- 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 /> 2j 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 E. Gomes Exc., Inc. Job No. Pic -Up ate <br /> R O. Box 369 <br /> Rio Vista, CA 94571 Unit No. / 2- <br /> (707) 374-2881 / SIGNATURE OF BUYER S <br /> EPA#CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> o - Injection Well <br /> Name QTY Measured ` ` 13 <br /> - Landfill <br /> 13 - Land Treatment <br /> EPA# D - BBL I] - TONS ���" ^OTHER ❑ - Surface I dment <br /> P _ <br /> -,a--- Other <br /> SIGNATU 'OF AUTHORIZED AGENT DATE <br /> TSDF TO GENERATOR <br />