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' LI19D WASTE MANAGEMENT, S. 42518 <br /> STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK,CA 93251 Approval# <br /> (805) 762-7366 <br /> Lease Scale Ticket # <br /> Well# // <br /> ' Approved Disposal Site Operator <br /> McKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> ' CompanyCf� <br /> Address y <br /> Description: ri Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler T <br /> ' Company / <br /> Address <br /> ' Truck# <br /> C. Delivery Date, n D. Invoice: Hauler <br /> i <br /> ' Date: . — ' Z/ WasteSource <br /> Quantity Tons Wash Out @ $ ea. <br /> �c 5� till <br /> Cost Per Ton Total Cost <br /> 'I certify that the above described wastewashauled to this approved disposal site and wa n acceptable <br /> waste as established by Order No. 72-256 of the California Regiona �Quality nt of Board.' <br /> ' Signature of Disposal Site Operator HAULER Signature of Licensed Hauler <br /> I <br />