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Waste Hauler Document Daily Field Ticket No. 452n7� <br /> 4 <br /> GENERATORDESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: Name: " 'f`<= Name: <br /> EPA# EPA# EPA# <br /> Address: L -r_. ' ` '�' Address: �:' -!�l t I Ifs Address: <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWELL WATER ❑ - OTHERM. <br /> Weight/Volume Units oLz' Container: ❑ Dump Truck 33-'_ 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 from.a 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. !II '� k ; yti.,r f ' %` =� '� <br /> t ` Pick-Up Date _Cr <br /> P. O. Box 369 <br /> Rio Vista, CA 94571 <br /> Unit NO. L t -' �,r' ae �,i'�� •-i f�.a..��7,/ <br /> (707) 374-2881i/SIGNATURE OF BUYER <br /> EPA#CAD076557370 y <br /> TSD FACILITY Method of Disposal: <br /> -�.' ❑ - Injection Well <br /> Name <br /> QTY Measured ' ❑ - Landfill <br /> ❑ - Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS {y��/ OTHER ❑ - Surface Impouadmn <br /> 4, C <br /> .o"-'Other <br /> SIGNATURE OF AUTHO , D AGENT DAT <br /> I <br /> GENERATOR COPY <br />