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State of California CIWMB 169 (Rev 4/04) California Integrated Waste ENFORCEMENT AGENCY NOTIFICATION Management Board Enforcement Agency: Official Use Only SWIS Number: County: Date Received: I. GENERAL INFORMATION Operation Name: y tZ t s Address: p, o. 0 3 City: o nState: pk Zip: 4� Phone: — _ O Fax: B-- r i Z o LLT La rt.. cu 1-1 Operator Name: g o v rt Address: fpp aLt 00-C4: i¢Ac State: CA ZIP: qS-3& Phone: aq y7 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 for more details Type(s) of Waste/Material Handled: Geespi o o J> Volume of Waste/Material Handled: Peak Loading: ❑ Cubic yards or ❑ Tons Annual Loading: ❑ Cubic Yards or E] Tons Days and Hours of Operation: MO aoe4 — AfU 21anY Operation Acreage: Brief Description of the Operation: I q _ / S. 31/c 96rCI I'l L &5Tes .inr�nLE, STar4c.0i/incr. Sae-je— . rang Se/¢ ^J LJa.i}e. a D ll¢Ce.A[ ac4LE95A/ED FINES L,J ILL 06 SiDLIG rpt Ae 1> d- '00M O057Tvtj III. DOCUMENTATION OF LOCAL NOTIFICATION (check one and submit with EA Notification) ❑ Proof of Compliance with the California Environmental Quality Act (CEQA). ❑ Correspondence from the local planning department that compliance with CEQA is not required for the operation to [$ 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. —i Signature of Land Owner: Date: I Signature of Operator: �� I Date: I `T I I ''GI / U ` Completion of this form is not required by regula own: 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.