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State of California Soli&Vaste Information System (VVIS) Department of Resources <br /> CalRecycle 37(Rev.7/17) '-Facility/Site/Operation Data Entry Form Recycling and Recovery(CalRecycle) <br /> ❑*** New SWIS Number KUpdate information (*❑ ) ❑Change in address or phone#s ❑Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number - ;,fh - DO W /LEA 3 9 - �- <br /> ❑*Facility Locator Information see: http://www.calrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx <br /> Facility/Site Name:/ <br /> Facility/Site Location/Address: 6--3 -73 <br /> Nearest City/Place Name: County: ^ qolaog;rz± ,State Ca Zip:915_fO f- 9ya3 <br /> Facility locator info: Decimal Degrees= Longitude: - ❑ ❑ ❑ . ❑ ❑ ❑ ❑ ❑ Latitude ❑ ❑ .❑ ❑ ❑ ❑ ❑ <br /> -or- Degrees, Minutes,and Seconds: Long:- Lat: <br /> Assessor Parcel Number(s): c> /3 / 40 37 <br /> Map#: Section: Township: Range: Base/Meridian: <br /> ❑*.(}perator(Business,Owner)Iufdrnmation <br /> Person/Operator Name/Company Name: �`L ) ma=r <br /> Last Name: r-ry First Name: ��� e MI: <br /> Title: Pd—e-4 �����"'�-�t Organization: <br /> MailingAddress: 3 �'"� 1"x,,e <br /> �/ <br /> City: � , State: e_'A Zip: ® Q © X®- If It © Q <br /> Phone Number: (�o�) ® © r- 10 It[) 1❑ FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> E-Mail Address: � .�C 6 y _ card• c-F�1+>' <br /> ❑*Land Owner(s) [t'roperty'Owner(s)]Information Q /� <br /> Person/Operator Name/Company Name: � 'e "_1 / iib�'r -"`J L'< <br /> Last Name: First Name: ME <br /> Title: nn Organization: <br /> Mailing Address: <br /> City: /";? State: 1�9 Zip: T IT®- ® 7 11 r7 <br /> Phone Number: r[Y ®-Q 0 0 FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> Email Address: <br /> * Required Signature fui�mittal Gall2ec cie with supportinoneits a�:d,map <br /> LEA or Operator or Owner signature: X 7 ti e4� Phone: V $-- 3 �',aDate: <br /> ❑ Supporting documents attached C3 Maps attached ❑All signatures and dates present on documents <br /> See :http://www.calrecycle.ca.eov/SWFacilities/Directory/MinimumData.aspx <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> ❑* Facility/Site 1 unit:,'Characteristics/Specifications:' / <br /> Unit Activity(s)name(s)and Code#: / 9— C)1?-ew ` <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: A/ <br /> Re2ulatory Status Operator Type Operational Status Inspection Frequency. V o-- <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): /17et r h"ve /6 <br /> ❑Unpermitted ❑State Active TonsNolume per Day: <br /> ❑Exempt ❑County Kinactive Permit Date: <br /> ❑EA Notification ❑City ❑Closed EA Notification date: <br /> ❑Excluded ❑ Private ❑ Clean Closed <br /> ❑Proposed ❑District [:]To be Determined <br /> List one or more Types of waste to be received/permitted(see back of this form for list of waste types/code <br /> ***Required CalRecycle staff signature (Received and reviewed for completeness) <br /> by: Phone Date <br />