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' LIQIIID WASTE MANAGEMENT, tc. 42475 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 <br /> (805) 762-7366 Approval# <br /> 2-0 9/ -fir/� <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# / � J /� <br /> Approved Disposal Site Operator <br /> MCKITTRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: 12 <br /> Company <br /> Address\,.,, <br /> Description: o soil �❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler --- <br /> ' - <br /> Company t# <br /> Address <br /> ' Truck# c— / <br /> C. Delivery Date: D. Invoice: Hauler <br /> ' Date: --2 F- 47 // <br /> ' 47 / Waste Source <br /> F-', S ,E�, <br /> Quantity T s Wash Out t7a $ ea. <br /> Cost Per Ton Total Cost <br /> ' 'I certify that the above des ribed�waste was hauled to this approved disposal site and was an acce able <br /> waste as esta Wt d b Order t 72-256 of the California Regional Waterality Control <br /> ' Signature of Disposal Site Operator HAULER Signature of Licensed Hauler <br /> 1 <br /> 1 <br />