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1 i • <br /> LIQUID WASTE MANAGEMENT, INC. 42494 <br /> 1 STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK,CA 93251 Approval # <br /> (805) 762-7366 <br /> Scale Ticket # <br /> 1 Lease <br /> Well# i� 177 ,.. <br /> 1 Ph# ��_ <br /> Approved Disposal Site <br /> Operator <br /> 1 McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> LIQUID WASTE DISCHARGE REPORT / <br /> Source: <br /> A. Liquid Waste <br /> Company ��t,'��Q� I '7 �C�t iT M <br /> 1 Address <br /> Description: 9 Soil ❑ Brine ❑ Drilling Mud ❑ Other. <br /> 1 B. Licensed Waste Hauler - 1� <br /> Company <br /> Address <br /> 1 Truck# ��I <br /> 1 0. Delivery Date: D. Invoic@: Hauler _ <br /> Data: �� — I Waste Source <br /> iS, � - <br /> 1 Quantity S, T s Wash Out @ $ ea. <br /> Cost Per Ton Total Cost <br /> 'I certify that the above d cribed waste was hauled to this approved disposal site and was an acceptable <br /> waste as ishe by der No. 72-256 of the California Regional W er Qu lity Control oard.'� <br /> 1 <br /> Signature of Licensed Hauler <br /> Signature of Disposal Site Operator HAULER <br /> 1 _ <br /> 1 <br /> 1 <br /> 1 <br />