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CALIFORNIA WASTE MANAGEMENT BOARD <br /> ,TATE OF CALIFORNIA <br /> SOLID WASTE FACILITIES PERMIT APPLICATION <br /> NM '71Rev.1/891 <br /> :NFOh,,.—eNi AGENCY FOR ENFORCEMENT AGENCY USE ONLY <br /> HLE NUMBER(PERMIT NUMBER) <br /> :OUNTY <br /> DATE RECEIVED FILING FEE <br /> "PE OF APPUCAIION <br /> 1. NEW SOLID WASTEDATE REVISION OF PERMIT ❑3. PERMIT REVIEW GATE ACCEPTED RECEIPT NUMBER <br /> FACILITY PERMIT <br /> 14, MODIFICATION OF PERMIT ❑5. EXEMPTION FROM PERMIT ❑6. FACIUTY CLOSURE DATE REJECTED CO SWMP REFERENCE PAGE(S) <br /> ❑i.AMENDMENT OF APPLICATION <br /> NOTE: -his form has been developed for multiple uses. It is the transmittal sheet for documents required to be submitted to the enforcement agency. See <br /> instructions on back for completing this application. <br /> NAME of FACILITY <br /> LOCATION OF FACILITY(GIVE ADDRESS OR LOCATION ALSO INCLUDE LEGAL DESCRIPTION BY SECTION,TOWNSHIP.RANGE BASE AND MERIDIAN IF SURVEYED OR PROJECTED 1 <br /> I. <br /> GENERAL TYPE OF FACILITY <br /> DESCRIPTION ❑ LANDFILL ❑ TRANSFER STATION ❑ RESOURCE RECOVERY FACILITY <br /> OF ❑ SUMP ❑ COMPOSTING ❑ LAND SPREADING <br /> FACILITY TYPE OF WASTES TO BE RECEIVED <br /> AGRICULTURAL ❑ CONSTRUCTION/DEMOLITION ❑ LIGUIDS(INCLUDES SEPTAGE) <br /> ❑ ASBESTOS ❑ DEAD ANIMALS ❑ MIXED MUNICIPAL <br /> ❑ ASH ❑ INDUSTRIAL ❑ SEWAGE SLUDGE <br /> ❑ AUTO SHREDDER ❑ INFECTIOUS ® TIRES <br /> ❑ WOOD MILL <br /> II OPERATION 1 EFFECTIVE DATE PROPOSED CHANGE(CHECK APPLICABLE BOKIESIf EFFECTIVE DATE <br /> 1 <br /> FACILITY <br /> ® <br /> INFORMATION COMMENCED ❑ WILL COMMENCE I ❑ DESIGN ❑ OPERATION 0 NO CHANGE 1 <br /> ! t <br /> AVERAGE ANNUAL LOADING(TPY) PEAK DAILY LOADING(TPO) FACILITY SIZE(A) EXPECTED CLOSURE YEAR — <br /> OWNER OF LAND(NAME) 1 ADDRESSTELEPHONE NUMBER <br /> III. t <br /> OPERATOR I ADDRESS <br /> INFORMATION FACILITY OPERATOR IF1aME) 1 <br /> For land disposal.if 1 <br /> operator Is different TELEPHONE NUMBER <br /> from land owner.attach ADDRESS WHERE LEGAL NOTICE MAY BE SERVED <br /> lease or franchise <br /> agreement <br /> I hereby acknowledge that I have read this application and the Report of Station or Disposal Site Information, and certify that the information given is true and <br /> accurate to the best of my knowledge and belief.In operating the solid waste facility,I agree to comply with the conditions of the permit and with federal,state and <br /> local enactments. <br /> SIGNATURE(LAND OWNER OR AGENTI SIGNATURE tFACILITY OPERATOR OR AGE N1) <br /> TYPED NAME TYPED NAME <br /> TITLF DATE (lit! RAT) <br /> IV, LIST OF A iTACHMENTS(CHECK THOSE APPLICABLE) <br /> U REPORT 7F;AGILITY!NFORMATION IREGUIRED! J ENVIRONMENTAL REVIEW REPORTS r— CLOSURE?!AN <br /> ❑ PERIODIC SITE REVIEW 1Z WASTE DISCHARGE REQUIREMENTS ❑OTHER REGULATORY AGENCY PERMITS <br /> LOCAL USE/PLCNNING PERMITS(REQUIRED) L-1 SWAT ❑OTHER <br />