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BAY HREH THNK & MHRINE TEL : 1-510-572-0745 Sep 29 , 92 10 : 09 No . 003 F' . 03 <br /> : .r----E/'��f [ - <br /> OGT 0 1 1932 LIQUID WASTE MANAGEMENT, INC. <br /> g38 <br /> STAR RTE. BOX 4, CORNER HWY. 33 AND HWY, 58 <br /> ENVIRONMENTAL HEALTH MCKITTRICK, CA 93251 <br /> PERMJ ? (845) 762.7366 Approval# <br /> Lease <br /> well# <br /> Scale Ticket # <br /> Ph# (j <br /> Approved Disposal Site Operator <br /> McKITTRICK W LIOUID WASTE MANAGEMENT, INC, <br /> LIQUID WASTE DISCHARGE REPORT <br /> _ A: Ligald Waste Source: <br /> Company ' ,< 7 ;�fr <br /> y <br /> Addross <br /> Doscription: ''`CT Soil Brine ❑ Drilling Mud ❑ Other <br /> B, Licensed Wasto Hauler <br /> Company <br /> Address <br /> 'truck A,..,G-11 .,�.._.,. <br /> I <br /> C. Delivery Date: l7. Invoice: Hauler <br /> Date r. Waste Source Lr L <br /> Quantity•-•� z� r Toa WashOut; $ ea. <br /> � •r — E <br /> ISbIC;.J <br /> Cost Par Ton Total Cpst <br /> "I certify that the above described waste was hauled to this approved di p s I site and'w"; acceptable <br /> wasto as a tahflshjd� ' Order No 72-266 of the California g(on ler_ u y C- t.gosh " <br /> ? Rta � <br /> Signature of Disposal Site Operator HAULER Signature of Licensed Hauler- <br />. s <br /> i <br />� t <br /> i <br />