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a <br /> 'oTATE OF CALIFORNIA <br /> REGIONAL WATER QUALITY CONTROL BOARD <br /> DEPARTMENT OF HEALTH SERVICES <br /> SOLID WASTE MANAGEMENT BOARD <br /> DEPARTMENT OF FORESTRY '1 <br /> I <br /> APPLICATION FOR <br /> FACILITY PERMIT/WASTE DISCHARGE <br /> This form Is to be used for filing a/an: (check all appropriate) FOR OFFICE USE UNI.y <br /> 1. *- REPORT OF WASTE DISCHARGE Form 200 Recd <br /> (pursuant to Division 7 of the State Water Code) Fee(RWOCS) (SWM8) <br /> 2. APPLICATION FOR A HAZARDOUS WASTE FACILITY PERMIT Letter to Discharger <br /> (pursuant to Health and Saiaty Code Section 25200) <br /> Report Recd <br /> 3. L_I APPLICATION FORA SOLID WASTE FACILITIES PERMIT Effective Date <br /> F1 <br /> U' Ipurwant to Government Code Section 66796.30) — <br /> 4. APPLICATION FOR A RUBBISH DUMP PERMIT CDF Notified <br /> (pursuant to Public Resources Coda Sections 4371-4375 and 44361 DOHS No. <br /> _ I SWMS No. <br /> _ ---_--------- I. FACILITY <br /> A. NAME OF FACILITY <br /> TEL[.NON[ . <br /> !QoroN_ -cxtv[_�5 — - (�i L( 1 X13"t'3`I Iu (c.1 <br /> al.wee. <br /> •. NAME OPFLEGALLEGAL OWNER OF FACILITY TAL{INON[• �T"'s l' 1A' <br /> :eew... <br /> al.eee. <br /> �. <br /> C.NAME UP •usINEES OPERA-NG FACILITY— ` rR^LEFN(o]xR)�• -- <br /> wq 3gbN— <br /> ur eooE <br /> 0. TYPEof Euunae•oPEwwTixa wauury 1�w <br /> E] Sole Proprietorship 11 Partnership 174 Corporation Government Agency <br /> E. NAME OF OWN9R R OF SURINR1a OPERATING FACILITY K—� TRL[.NONR <br /> n .....i a. .. <br /> al.Gee. <br /> -- -- 11. REASON FOR FILING -- <br /> cNaC.•11 A..we.wuv. <br /> A. New discharge or facility D. Change in character of discharge G.8 Change in business operating facility <br /> B. Existing discharge or facility E. Change in piece or method of die:,O al H, Enlargement of existing facility <br /> C. Increase in quantity of discharge F. Change in design or Operation I. Other(explain below) <br /> - —_—— _—_—_ Ill. TYPE OF OPERATION <br /> c <br /> C.ALL w..wo.wura: <br /> A. Transfer station D. Sewage treatment G. Woodwaste site <br /> �a�—"II <br /> B. 8 Solid waste disposal site E. 1�1 Industry IoMite disposal facility) H.8 Other(explain below) <br /> C. Hazardous waste disposal site F. �u-j Industry(discharge to sewer) <br /> -_- - IV. TYPE OF WARTS ------ <br /> eN[ea ALL APrworwur[: <br /> A Sawage,sewage sludge,and/or E. Agricultural wastes I. Inert materials <br /> septic Ink pumpings <br /> B. Industrial wastes F. Animal wastes J. Dead animals <br /> C. Municipal solid wastes G. Forest product wastes K. Tires <br /> D. Hazardous Wastes H. Construction/demolition wastes L. Other(explain below) <br /> V. SITE DESIGN CAPACITY <br /> A..wuaer w.ua.new ow cA.wenr oasroe.o.uunoN ow uw.Ar[cw.Acrtr a u.[•a.acr.xcr sa AR• <br /> FORM iH (Rev.a/Gal to VER) <br />