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Y <br /> IL III <br /> ' -Tvapte Hauler Documerit Daily Field Ticket No. f 2 45486 <br /> GENERATOR ! DESIGNATED TSD" FACILITY ALTERNATE TDS FACILITY <br /> Name: 7' ! Name: ! Name: <br /> EPA# EPA# EPA# <br /> Address: Address:�f /�i��/r r Address: <br /> .K io <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - G WELL WATER -n OTHER iY64 Y-(f <br /> Weight/Volume Z01 Units Container: ❑ - Dump Truck E Tank Truck <br /> This materik is nonhazardous because: H <br /> 1)it is a drillingmud containing only the additives listed by the Department in its exemption <br /> letter and contains`go significant concentrations of toxic materials from natural sources,or <br /> 2)is a sulfur-dioxidftcrubber solution from.a sodium hydroxise or sodium carbonate oil <br /> field handling as a hazardousSte. <br /> boiler scrubber System, and possesses no characteristics that would require its SIGNATURE OF AUTHORIZED AGENT DATE <br /> 'st <br /> TRANSPORTER ,� <br /> Warren E. Gomes Ex 2340 Job No.�✓� ��'aH1�r�9C �lG�� �'1� j Pick- Dat � � �' <br /> P. O. Box 369 f <br /> Rio'Vista, CA 94571 Unit No. �� l <br /> (707) 374-2881 SIGNATURE OF BUYER <br /> , ,,,..EPA.#CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> �: o - Injection Well <br /> Nine � QTY Measured � � r o - Landfill <br /> o - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS , d- OTHER o - Surface Im umment <br /> 13 - Other �!'�� <br /> -3 . <br /> SIGNATURE OF AUTHORI AGENT DATE <br /> TSDF TO GENERATOR <br />