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' LIAD WASTE MANAGEMENT tc. 42477 <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# O <br /> Approved Disposal Site Operator <br /> MCKI TRICK LIQUID WASTE MANAGEMENT, INC. <br /> LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: ^O n <br /> ' Company { I <br /> Address <br /> ' Description: ---❑ Soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler T <br /> ' Company , <br /> r <br /> Address <br /> ' Truck* "�)/ <br /> C. Delivery <br /> yDDate: D. Invoice: Hauler <br /> ' Date S / Waste Source <br /> Quantity /2, Ton Wash Out @ $ ea. <br /> L2� > <br /> Cost Per Ton Total Cost <br /> 'I certify that the above desc 'bed waste was hauled to thisapproved disposal site and was an acceptable <br /> waste as estab ished bI Order 72-256 of the California Regions ter Quality Control Board.' <br /> ,� I A, <br /> ' Signature of Disposal Site Operator HAULER �— Signature of Licensed Hauler <br /> t <br /> I• <br />