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A9F. 'JI 0/.611 r'-t1A cr SOLIU NwS4C -A NA I.F-I tiT hC e.pp <br /> OLID}7V°ASTE FACILITY PERM! PPLICATION <br /> e1I.1B C.-I-lT froE M' bT/' <br /> C'NC1:MCNT AGENCY FOR ENFORCEMENT - - <br /> ^ FILE NUMBER- PERMIT NUMBER A <br /> GENCY USE ONLY <br /> DATE <br /> RECEIVED PILING PEE <br /> PC OF APPLIC ATtOd �..__-.__. .-.__ _ -._-.-•..�I C�J� -✓ Cs` <br /> Y. APPLICATION DATE ACCEPTED -..---- RECEIPT NUMBEp <br /> FOROR SOLID WASTB <br /> I. N0710E OF FACILITY !. APP LIC AT®ON FOR MODIFICATION <br /> OPERATION • PERMIT • OF PERMIT <br /> 1. AMENDMENT <br /> DATEPERMITISSUED CO SWM►''REFERENCE PAGE �- <br /> OF <br /> APPLICATION S. APP LIGATION FOR REVIEW <br /> NOTE: This form has been developed for multiple uses. It is the transmittal sheet for documents required <br /> to be submitted to the enforcement agency. *A Report of Station or Disposal Site Information <br /> or an amendment thereto must be submitted with this form. <br /> NAME OF Fn CfLITY <br /> _ -- - - <br /> LOCATION OF FACILITY GIVE ADDRESS OR LOCATION DESCRIPTION BY SECTION, TOWNSHIP, RANGE. COUNTY _ <br /> TYPE OF FACILITY. .._-_.__._____ __ ....... <br /> 1. ryF-,-���"� <br /> i " SOLID WASTE DISPOSAL SITE _Q TRANSFER/PROCESSING STATION (INCLUDES RESOURCE RECOVERY <br /> GENERAL ---'-----'--- <br /> --•------'-"'••--.. .--- ----. ___._..--._......_- -.-_ - ___ .- ._ .-'-'---- .. - __ <br /> r TYPE OF WASTES TO BE RECEIVED <br /> DESCRIPTION <br /> RESIDENTIAL REFUSE ❑ CONSTRUCTION/DEMOLITION WASTES ❑ NA$ARDOUS WASTES <br /> O F i <br /> FACILITY COMMERCIAL SOLID WASTES SEWAGE SLUDGE C—� AGRICULTURAL WASTES <br /> TIRES LIQUIDS/SLURRIES I I SEPTIC TANK PUMPINGS <br /> I 11--11 <br /> OTHER (SPECIFY) _ p <br /> 11 <br /> OPERA <br /> T) N ,°. 4 I EFFECTIVE PROPOSED CHANGE (CHECK ONE OR BOTH) I EFFE GTIVE� <br /> DATE DATE _.._ <br /> NFC RMATION COMMENCED T £ 1 ( DESIGN OPERATION <br /> OWNER OF PROPCRTpYq^T A MEyF,-�r-.-•q� I ADDRESS <br /> ^sy <br /> III. � C-�pf _ T_.. d -- ".F_r-`- '✓ . .. ._ _I.__ ".S✓"_'. - ..- - - ---. 4�', l.-^ `-------..._ <br /> F­CPF_RATOR�NAME 1ADDR ESS <br /> OPERATOR <br /> Jl _ <br /> ADDRESS WHERE LEGAL NOTICE MAY BE SERVED <br /> �r- - <br /> FILING FEC ENCL09£D <br /> IV. <br /> 1 hereby acknowledge that I have read this application and the Report-of Station or Disposal Site Informa- <br /> tion, and certify that the information given istrueand accurate to the best of my knowledge and belief. <br /> In operating the solid waste facility. 1 agree to comply with the conditions of the permit and with state <br /> and local enactments. <br /> NA RE ( AGENT .% _ SIGNATURE ( •-_-OR AGENT( --^_—_~--- <br /> NAME --_-,.ti_._ <br /> Tr PED NA E-`-----------•_ ---.�-.�.._ <br /> m <br /> y � ATE <br /> r � CHECK A UP" <br /> P OPRIATE BOX -- <br /> 4FORCEMENT <br /> i APPLICATION APPROY ED - AP►LICATPON DENIED <br /> AGENCY _ -N-1 <br /> _ _ _ <br /> SIGNATU - T14LL' 1-4-N D PRITED NI@vME_ DATE AND I r L r PHO NE NO. <br /> USE ONLY I <br /> IIATE RECEIVE CHECK APPROPRIATE BOX <br /> SOLID OBJECT TO <br /> WASTE <br /> t CONCUR. PROPOSED PER <br /> PROPOSED PE RMIT MIT AGENCY DEN7AL UPHELD <br /> I <br /> A N A G E M E N T <br /> &CARD t OTHERJSPECIF Y, <br /> S•a N._'UNE TITLE R 1 _ - -- - — — — _---_ <br /> ONLY � 1h TED JA ME DATE AND TELEPHONE ND. <br /> r � AND F <br />