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^/ J <br /> f <br /> N NMHAZA r SUS Waste Hauler Document'Daily Field Ticket No. Al 314? 45172 <br /> GENERATOR DESIGNATED TSD FACILITY ALTERNATE TDS FACILITY <br /> Name: ° <br /> Name: Name: <br /> EPA# EPA# EPA# <br /> Address: (L-?d-4 t<r,� <br /> Address: j Address: <br /> Order Placed: Order Date: <br /> WASTE ❑ - DRILLING MUD ❑ - GASWLL WATER Efu OTHER <br /> - °.%- <br /> Weight/Volume Container: ❑ - Dump Truck ['2- 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 <br /> handling as a hazardous waste. DATE <br /> TRANSPORTER <br /> Warren E. Gomes Exc., Inc. Job No. ' Pick-Up Date <br /> P O. Box 369 <br /> Rio Vista, CA 94571 Unit No. - <br /> (707) 374-2$$1 SIGNATURE OF BUYER <br /> EPA.#CAD076557370 <br /> TSD FACILITY Method of Disposal: <br /> Name0 - Injection Well <br /> QTY Measured d- Landfill <br /> b- Land Treatment <br /> EPA# ❑ - BBL ❑ - TONS �0- OTHER o - Surfacelmpoe event <br /> 13 - Other S' //7 <br /> -03 <br /> SIGNATURE OF AUTHORIZED <br /> J ENT GATE <br /> TSDF TO GENERATOR <br />