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LI09101 WASTE MANAGEMENT, # 42481 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 n Approval# <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# :7 /S <br /> ' Approved Disposal Site Operator <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> ' A. Liquid Waste Source: —� /� / <br /> Company O / 7,—C, (— h �1_ /f ' �/ <br /> Address <br /> ' Description: -a soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> Company <br /> Address <br /> ' Truck# <br /> C. Delivery Date: D. Invoice Hauler <br /> Date: Waste Source <br /> s. <br /> ' Quantity �l ons Wash Out. @ $ ea. <br /> Cost Per Ton Total Cost <br /> 'I certify that the above de ibed waste was hauled to thisapproved di osal s' and v4s an acceptable <br /> ste as esta oled Order No. 72-256 of the California Region I Wate ality bntrol Board.' <br /> ' ignature of Licensed Hauler <br /> Signature of Disposal Site Operator HAULER <br />