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STATE OF CALIFORNIA <br /> CALIFORNIA INTEGRATED WASTE MANAGEMENT BOARD <br /> REGIONAL WATER QUALITY CONTROL BOARD <br /> APPLICATION FOR SOLID WASTE FACILITY PERMITMIASTE DISCHARGE REQUIREMENTS <br /> CRNMS E-1.77(Rev.8-01114j <br /> NOTE:This form has been developed for multiple uses. It is the transmittal sheet for documents required to be submitted to the appropriate agency. <br /> Please refer to the attached instructions for definitions of terms and for completing this application form in a complete and correct manner. <br /> FOR OFFICIAL USE ONLY <br /> SWIS NUMBER: FILING FEE: RECEIPT NUMBER: DATE RECEIVED: <br /> �7c�Z�, 'Z-J-Z-( " <br /> ATE ACCEPTED: DATE REJECTED: ACCEPTANCE DATE OF <br /> p( INCOMPLETE APPLICATION: <br /> 2 , D -t>j DATE DUE: <br /> Part 1.GENERAL INFORMATION <br /> A ENFORCEMENT AGENCY: B.COUNTY: <br /> C.TYPE OF APPLICATION(Cheek one box only): <br /> M 1. NEW SWFP and/or WDRS 114.PERMIT REVIEW <br /> 112. REVISION OF SWFP and for WDRS 5.AMENDMENT OF APPLICATION <br /> 113. EXEMPTION and/or WAIVER 06.RFUROWD/JTD AMENDMENTS <br /> Part 2.FACILITY DESCRIPTION <br /> A. NAME OF FACILITY: <br /> 5c o-77S 54A) 70AC/a1A) CovA TY RF��IoAIA L ev x4P0s /V-6 -gel Le®y <br /> B. LOCATION OF FACILITY: <br /> 1. PHYSICAL ADDRESS OR LOCATION AND ZIP CODE: <br /> 23 90 Fte C)CI L®A✓dC-AJ, 9,23 <br /> 2. LATITUDE AND LONGITUDE: <br /> 59 00 7-4r 6z N tz l ®r 37, 53 A) <br /> 3. LEGAL DESCRIPTION OF PERMITTED BOUNDARY BY SECTION,TOWNSHIP,RANGE,BASE,AND MERIDIAN.IF SURVEYED: <br /> S,F, .4 c14,!;7-d ~f kli774 co w,,06Sr®As' 4 1 AAM beLJA1dlA,P-f�-s <br /> C.TYPE OF ACTIVITY:(Check applicable boxes): <br /> Ell.DISPOSAL M3.TRANSFORMATION [:]5.OTHER(describe): <br /> a. TYPE: <br /> ®2.COMPOSTING f74.TRANSFER/PROCESSING FACILITY <br /> a. TYPE: ❑CHECK HERE IF RECYCLABLE MATERIALS ARE RECOVERED PRIOR TO TRANSFER/PROCESSING. <br /> D.CONFORMANCE FINDING INFORMATION(CIWMP): <br /> �1.FACILITY IS IDENTIFIED IN(Check one): <br /> SITING ELEMENT DATE OF DOCUMENT PAGE# <br /> NONDISPOSAL FACILITY ELFAREAN7" DATE OF DOCUMENT j� Z o o Z- PAGE# 2 <br /> 02.FACILITY IS NOT REQUIRED TO BE IDENTIFIED IN SITING ELEMENT OR NONDISPOSAL FACILITY ELEMENT <br /> E.TYPE OF PERMITTED WASTES TO BE RECEIVED:(Check applicable boxes): <br /> MI.AGRICULTURAL ❑6.CONSTRUCTIOWDEMOLITION E:]11.LIQUIDS <br /> 72.ASBESTOS O Friable O Non-friable M7.CONTAMINATED SOILS ❑12.MIXED/MUNICIPAL SOLID WASTE <br /> F�3.ASH p6.DEAD ANIMALS M13.SEWAGE SLUDGE <br /> ❑4.AUTO SHREDDER F-19.INDUSTRIAL ❑14.TIRES <br /> [-]10.INERT [:]IS.OTHER(describe): <br /> 05.COMPOSTABLE MATERIAL(describe): /46gleiltr e.4L WA.S`rE°b'ARK F/A)CS 4,gle '- P®MACE,RILE ffrfLLS;CdrlCkelU At- 'L_ <br /> Page 1 <br />