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APPENDIX - FORM 200 <br /> :iTATE OF CALIFORNIA <br /> REGIONAL WATER QUALITY CONTROL BOARD <br /> DEPARTMENT OF HEALTH SERVICES <br /> SOLID WASTE MANAGEMENT BOARD <br /> DEPARTMENT OF FORESTRY <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 ONLY <br /> 1. j REPORT OF WASTE DISCHARGE Forth 200 Recd <br /> (pursuant to Division 7 of the State Water Code) Fee(RWQCBI (SWMB) _ <br /> 2. n APPLICATION FOR A HAZARDOUS WASTE FACILITY PERMIT Letter to Discharger <br /> (pursuant to Health and Safety Code Section 25200) Report Recd _ <br /> 3. APPLICATION FOR A SOLID WASTE FACILITIES PERMIT Effective Date <br /> (pursuant to Government Code Section 66796.30) — <br /> 4. APPLICATION FOR A RUBBISH DUMP PERMIT COF Notified <br /> (pursuant to Public Resources Code Sections 4371-4375 and 4438) OOHS No. <br /> SWMB No. <br /> —_-- —_ 1. FACILITY <br /> A. NAM[ OF FACILITY <br /> QUALITY ASSURED PACKING INC. ( 20 931-6700 <br /> •,a.{., <br /> ?, <br /> B. NAME OF LGGAL OWNER OF FACILITY <br /> Same as A <br /> •00+[3[ n,-coo{ <br /> C. NAME OF BUSINC55 OPERATING FACILITY T{LL•«p«{ <br /> Same as A <br /> D. TYPE of BUSINESS OPERATING FACILITY <br /> ElSole Proprietorship 1:1 Partnership ® Corporation F] Government AQ-ncy <br /> G. NAME OF OWNCR 5 OF BUSINi53 OPERATING FACILITY T[LL•«o«x + <br /> Gerald Chacon or Chuck Risner ( 209 ) 931-5700 <br /> ..00w[rf ««{+[ L[G wL«OTICG MA• .{ i{RV{O _,.GOOG <br /> _ Same as A _ <br /> It. REASON FOR FILING <br /> A. �� New discharge or facility D. Change in character of discharge G. Change in business coeratino"aciiit, <br /> 6. I` I Existing discharge or facility E. X Change in place or method of disaosal H. Enlargement of eca:ng fauiicy <br /> C. [XI Increase in quantity of discharge F. Change in design or operation I. Other(explain bet-,v) <br /> 111. TYPE OF OPERATION <br /> A. Transfer station D. Sewage treatment G. Woodwaste site <br /> S. Solid waste disposal site E. Industry(on-site disposal facility) H. XI Other(explain bele-) <br /> C. Hazardous waste disposal site F. Industry(discharge to sewer) <br /> Disposal and treatment on agricultural land. <br /> IV. TYPE OF WASTE <br /> A. Sewage,sewage sludge,and/or E. <br /> septic tank pumpin¢s Agricultural wastes I. Inert materials <br /> S. Industrial wastes F. Animal wastes J. Dead animals <br /> C. Municipal solid wastes G. Forest product wastes K. Tires <br /> 0. Hazerdous wastes H. Construction/demolition waste, !_ Other(explain be_w) <br /> V. SITE DESIGN CAPACITY <br /> rowL•no«o+ —T—A— cw•wc­ c.uF{ r[•[cr•«c• •[.+sl <br /> 5 years <br /> o{M too ({Ev. 3/+e( 10 VER) <br />