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r L104PID WASTE MANAGEMENT, 0c. 42483 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval# <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# <br /> 1 Appro%ed Disposal Site Operator <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> ' Company �t' <br /> Address <br /> ' Description: 'M Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> ' Company <br /> Address <br /> ' Truck# <br /> C. Delivery Date: G D. Invoice: Hauler <br /> ' Date:,�—.�a — �1 Waste Source <br /> )E- <br /> Quantity 17, -2 Tons Wash Out: @ $ ea. <br /> Cost Per Ton Total Cost <br /> ' 'I certify that theabove de bed waste was hauled to this approved disposal site and was an acceptable <br /> waste as estab'shed y Or r No. 72-256 of the California Regional W er Quality Co uol;Board.' <br /> 1 Signature of Disposal Site Operator HAULER Signature of Lice ed Hauler <br /> i <br />