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' LIQUID WASTE MANAGEMENT, I11 42493 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 Approval # <br /> (805) 762-7366 <br /> TY/� <br /> 1 —;<? os/. 2y <br /> ' Lease Scale Ticket # <br /> Well# <br /> Ph# <br /> ' Approved Disposal Site Operator <br /> ' McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> LIQUID WASTE DISCHARGE REPORT <br /> ' A. Liquid Waste Source: � /� <br /> // <br /> Company <br /> Address <br /> Description: Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> 1 Company <br /> Address <br /> ' Truck If <br /> C. Delivery Date: D. Invoice: Hauler <br /> ' Date: C V--'L Waste Source <br /> Quantity �Tons Wash Out: @ $ ea. <br /> S. <br /> G <br /> Cost Per Ton Total Cost <br /> ' 'I certify that the above described waste was hauled to this approved disposal silo and was an acceptable <br /> rae Regional waste as established by No. 72-256 of the California Regionaater, ualitlL Control Board.' <br /> ' S'g t of 'Is osal e perato HAULER Ignature of Licensed Hauler <br /> 1 <br /> 1 t <br />