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i LISID WASTE MANAGEMENT,ZNC. 42478 <br /> � 4 <br /> ' STAR RTE. BOX 4, CORNER HWY. 33 AND HWY. 58 <br /> MCKITTRICK, CA 93251 Approval # <br /> (805) 762-7366 <br /> 3-:? <br /> Lease Scale Ticket # <br /> ' Well# <br /> Ph# ? /5 <br /> ' Approved Disposal Site Operator <br /> MCKITiRICK LIQUID WASTE MANAGEMENT, INC. <br /> ' LIQUID WASTE DISCHARGE REPORT <br /> A. Liquid Waste Source: <br /> ' Company <br /> Address dr ,,. <br /> iDescription: -,o soil ❑ Brine ❑ Drilling Mud ❑ Other <br /> B. Licensed Waste Hauler <br /> ' Company <br /> Address <br /> ' Truck# <br /> C. Delivery <br /> -7Date: G� D. Invoice:: ' Hauler <br /> ' Date: 7 '_20 / / v Waste Source <br /> Quantity / Tons Wash Out: @ $ ea. <br /> Cost Per Ton Total Cost <br /> ' 'I certify that the above desc d waste was hauled to this approved disposal site and was an acceptable <br /> waste as estab' d b Orde No. 72-256 of the California Regional Water Qualms ontrol Board.' <br /> iSignature of Disposal Site Operator HAULER Signature of Licensed Hauler <br /> 1 <br /> P <br /> i' <br /> i <br /> 1 <br />