Muhick & GPR Waste Form

I declare that the information in Part A is correct and complete. I hereby declare that the contents of this consignment are fully and accurately described
above by the proper shipping name, are properly classified and packaged, have dangerous goods safety marks properly affixed or displayed on them,
and are in all respects in proper condition for transport according to the Transportation of Dangerous Goods Regulations.

COMMENTS

F098 – November 2022

Muhick & GPR Responsible for Waste Form: H3SE REGULATOR To order forms, phone .

FORM COMPLETION INSTRUCTIONS

Distribution: 1. Generator completes PART A and has transporter complete PART B. Generator retains one copy.
2. Transporter carries 3 copies with shipment and gives them to the receiver. Note: If a serious discrepancy is the r e s u l t of an activity by the transporter (e.g., truck spill),
the transporter must notify the generator within 24 hours.
3. Receiver completes Part C, noting any discrepancies, then returns one copy to the transporter and one copy to the generator (to be sent no later than 30 days after the waste
shipment date) and retains one copy. Note: If a serious discrepancy is noted, the generator and transporter must be notified within 24 hours.
4. Upon being notified of a serious discrepancy, the generator investigates the discrepancy and takes corrective action. The AER must be notified immediately if a serious
discrepancy is noted. If the generator cannot reconcile discrepancies within 60 days after the date of the waste shipment, the AER must be notified. Investigation results
and corrective action are to be reported in the comments section.
5. Companies wishing to use the form for non-dangerous oilfield wastes must indicate on the form that the waste is non-dangerous.
NOTE: All parties must retain FORM copies and supporting data for a minimum of 2 years.
Completion: Some information listed below may not be applicable in all situations.

Part A – Generator (Consignor) Part C – Receiver (Consignee)

- Identify Company Name, Operator/Business Associate Code (AER-assigned codes), and - Identify Company Name and Business Address.
Business Address. - Identify Receiving Site Location (reported as LSD-Sec-Twp-RgeW M), and Operator
- Identify Source Site Location (reported as LSD-Sec-Twp-Rge W M), Licence Type Code/BA Code (AER-assigned codes).
(W - Well, P- Pipeline, F- Facility), and Licence Number (AER-assigned codes). - Quantity Received - Report to nearest 0.01 tonne, 0.01 m3, 0.1 kilogram, 0.1 litre.
- Identify Intended Receiver and Receiving Site Location (reported as LSD-Sec-Twp-RgeW M). - Indicate Units of shipment (t = tonne, m = m3, kg = kilogram, L = litre).
- Identify Waste Code (AER-assigned codes; see appendix 2 of Directive 058). - Identify Oil/Water/Solid %.
- Identify if the waste is non-dangerous (N) or dangerous (D). - Handling Code - Enter code for method of handling:
- UN Number - Obtained from Transportation of Dangerous Goods Regulations (TDGR).
- TDG Shipping Name (DOW) from TDGR or Common Name (non-D). 01 Storage Facility (specify final treatment/disposal) 13 Biodegradation Facility
- Classification - Obtained from TDGR. 02 Transfer Station (specify final treatment/disposal) 14 Small Oilfield Waste Incinerator
- Packing Group: I - Very Dangerous 03 Oilfield Waste Processing Facility 15 Used Oil Recycler
II - Dangerous 04 Class Ia Disposal Well 16 Recycling Facility (excluding used oil)
Ill - Moderately Dangerous 05 Class lb Disposal Well 17 Swan Hills Facility
- Quantity Shipped - Report to nearest 0.01 tonne, 0.01 m3, 0.1 kilogram, 0.1 litre. 06 Class II Disposal Well 18 Road Spreading
- Indicate Units of shipment (t = tonne, m = m3, kg = kilogram, L = litre). 07 Cavern 19 Biodegradation (on-site)
- Identify the Number and Code of Packaging 01- drum 02 - tank 03 - bulk 04 - carton 08 Class I Landfill 20 Burial (on-site)
05 - bag 06 - roll-off or lugger 07 - other 10 Class II Landfill 21 Other (specify)
- Handling Code - See Part C – Receiver (Consignee) for appropriate handling code. 11 Class Ill Landfill 22 Waste Transport by Pipelines
- Special Handling/Emergency Instructions - Self-explanatory. 12 Thermal Treatment 23 Manufacturer
- Identify Date and Time Shipped.
- Print Name, Telephone/Cellular Numbers, and Sign form. - Transporter Decontaminated - Enter Yes or No.
- Provide 24-Hour Emergency Telephone Number. - Identify Date and Time Received.
- Identify Discrepancies - Self-explanatory.
- Print Name and Telephone Number, and Sign form.

Part B – Transporter (Carrier) Comments:

- Identify Company Name, Business Address, Date, truck Unit No., and Telephone and Fax
numbers.
- Print Name and Sign form.