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' LIQUID WASTE MANAGEMENT, INC. 42515 <br /> STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval# <br /> ' ao9r- ;2 <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 /> company <br /> Address V <br /> Description: 0 soil 0 Brine Ell Drilling Mud 0 Other <br /> 1 B. Licensed Waste Hauler <br /> r— <br /> Company V / ' -i ' 7 <br /> ' Address <br /> Truck# <br /> ' C. Delivery Date: D. Invoice: Hauler <br /> �� <br /> Date: .� 9- X Waste Source <br /> QuantityIn, Tons Wash Out: @ $ ea. <br /> L. f/�7`-� bbts. <br /> Cost Per Ton Total Cost <br /> '1 certify that the above described waste was hauled to this approved disposal site and was an acceptable <br /> waste as established by Ordgr No. 72-256 of the California Regional Water puality Control Board.' <br /> � L"�ft! K`i % �ri• Z.r'1,ri• . . ed"1�'• .1(�i�� <br /> Signature of Disposal Site Operator HAULER Signature of Licensed Hauler <br />