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' LIQA WASTE MANAGEMENT, A 42517 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval <br /> pral# <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# / %7r <br /> ' Approved Disposal Site Operator <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> ' Company <br /> Addressr-i <br /> ' Description: uu Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> ' _ c. <br /> Company � 7� <br /> Address / <br /> ' Truck <br /> C. Delivery Date: D. Invoice: Hauler <br /> c� } <br /> Date: � � � ! / ,1 Waste Source <br /> Quantity Tons Wash Out @ $ ea. <br /> bbls. <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 Order No. 72-256 of the California Regional Water 9ualit, Control Board.' <br /> ' Signature of Disposal Site Operator HAULER Sign lure of Licensed Hauler <br /> , <br />