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' LIQ ID WASTE MANAGEMENT, C. 4480 <br /> Y <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK,CA 93251 Approval# <br /> (805) 762-7366 <br /> Oil <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# <br /> 1 Approved Disposal Site Operator <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> ' A. Liquid Waste Source: T ,-GC <br /> Company <br /> Address <br /> Description: Lr soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler /J) T ,vl� <br /> Company / S- ' / / <br /> Address <br /> ' Truck# 30 Z <br /> C. Delivery Date: D. Invoice: Hauler <br /> ' Date: ZS - ! S Waste Source r/ <br /> ' Quantity 7, T ns Wash Out: @ $ ea. <br /> Cost Per Ton Total Cost <br /> ' 'I certify that the above de cribed waste was hauled to this approved p sail si a w an acceptable <br /> este as&estpbshe y a der No. 72-256 of the California Regio ail at u ntrol Board.' <br /> � Yp <br /> Signature of Disposal Site Operator HAULER Sign e.of Licensed Hauler <br />