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State of California CIWMB 169 (Rev 4/04) ENFORCEMENT AGENCY NOTIFICATION California Integrated Waste Management Board Enforcement Agency: Official Use Only SWIS Number: County: Date Received: I. GENERAL INFORMATION Operation Name: �Ionj -PjTerz,P12.t s E Address: P. o. o y 2if!43 City:I U n t o ii CtnolState: I r A Zip: 19 y Phone: _ _ OjIq Fax: g— rl, i nT � o LT ioo r. • eu Operator Name: E ^c o v SE Address: 21SVO HoLLY o2 City: 2Ae- State: eA Zip: gS30 Phone: Si0 _94 07 Fax: Land Owner: Address: City: State: Zip: Phone: Fax: It. OPERATION INFORMATION Authorizing Eligibility (State Section of 14 CCR Division 7, Chapter 3 or 3.1): See back far more details 8 ` 2. Type(s) of Waste/Material Handled: Q&EN yvi9srs 1A/0 o 0 Volume of Waste/Material Handled: Peak Loading: ❑ Cubic yards or ❑ Tone I Annual Loading: ❑ Cubic Yards or ❑ Tone Days and Hours of Operation: 7' ND;q _U 011'U2p„Y Operation Acreage: jq Brief Description of the Operation: I q- /15-•3ys f)Grr Kr4L Ij &5W --s cm LE 5 To r c I 541-9- -f GJa+ t-t- r0dAAC*5 4-w !6 n •-S e cAt VeAl t enao u6 ecec V f. ao0 O AiVQ Se-ga&^l 77-JEn/ 1?6K0e G2GEi�j SGkZSOAISD Flour ES W rt•- /3E STDue- et/en •t e'on.rPosf-C7lJ- Ill. DOCUMENTATION OF LOCAL NOTIFICATION (check one and submit with EA Notification) ❑ Proof of Compliance with the California Environmental Quality Act (CEQA). EJ from the local planning department that compliance with CEQA is not required for the operation to obtain obtain local land use approval. Nr Written notice to the local planning department of the operator's intent to commence operations. IV. OWNERIOPERATOR CERTIFICATION I hereby certify under penalty of perjury that the information provided is true and accurate to the best of my knowledge and belief. Signature of Land Owner: Date: Signature of Operator: Date: � r I Completion of this form is not required by regula ion; however, it will provide the enforcement agency with the information required by 14 CCR 18103.1. • A separate Notification is required for each eligible operation.