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- LIQUID WASTE MANAGEMENT, INC. 42490 <br /> STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval# <br /> 1 Lease Scale Ticket # <br /> Well# <br /> ' Ph# r U C <br /> Approved Disposal Site Opera'ar <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> LIQUID <br /> ,WASTE <br /> �DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> Address\ ,,., <br /> Description: 'CJ soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> 1 Company <br /> Address <br /> 1 <br /> Truck# m- a <br /> ' C. Delivery Date: D. Invoice: Hauler <br /> Date: aste Source <br /> a � S • E-- <br /> ' Quantity, « T s Wash Out: @ $ ea. <br /> Cost Per Ton Total Cost <br /> ' "I certify that the above descri d waste was hauled to this approved di posal site and was an acceptab <br /> e asZesta., ed b de No. 72-256 of the California Re ion Water Qu li Control Board.'Y 9 tY�.I ri D <br /> Signature of Disposal Site Operator HAULER Signature of Licensed Hauler <br /> 1 <br />