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! LIQUID WASTE MANAGEMENT, INC. 42492 <br /> STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval# <br /> -3z o%/ -zy <br /> ! Lease Scale Ticket # <br /> Well# —7 <br /> ! Approved Disposal Site Operator <br /> ! MCKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> ! Company 4 z'/'a /'../ <br /> ! Addresss�,, I <br /> Description: 0 Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> ! B. Licensed Waste Hauler <br /> 7 <br /> Company � ' � _ 77 -7-,7 ( ( <br /> Address 1 <br /> Truck# <br /> ! C. Delivery Date: D. Invo Hauler <br /> Date: ?5 JL� Waste Source <br /> �. S . � <br /> Quantity 17, s Wash Out (7a $ ea. <br /> Cost Per Ton Total Cost <br /> ! 'I certify that the above described waste was hauled to this approved disposal site and was an acceptable <br /> waste as establi hed bylOrder No. 72-256 of the California Rk nal Wate Quality Control <br /> Signature of Disposal Site Operator HAULER Signature of Licensed Hauler <br /> ! <br /> ! <br /> ! <br /> ! <br />