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State of California Solid 0aste Information System (SOS) Department of Resources Recycling <br /> CalRecycle 37(Rev.12/17) and Recovery(CalRecycle) <br /> Facility/Site/Operation Data Entr,X Form <br /> ***New SWIS Number* Update information(*El )E]Change in address or phone#snn1-JRequest to Archive <br /> CALRECYCLE USE ONLY Facility/Site/Operation SWIS Number 39 _AA -0057 /LEA - <br /> � i drS uformaton see: Minimum Data Required to Issue New SWIS Number <br /> Facility/Site Name:Green Earth Recovery <br /> Facility/Site Location/Address:20500 Holly Drive <br /> Nearest City/Place Name:Tracy County:San Joaquin State Zip:95304 _ <br /> Facility locator info: Decimal Degrees=Longitude: - ❑ ❑ ❑ .❑ ❑ ❑ ❑ ❑ Latitude ❑ ❑ .❑ ❑ ❑ ❑ ❑ <br /> -or- Degrees,Minutes,and Seconds: Long:- Lat: <br /> Assessor Parcel Number(s):21216010 <br /> Map#: Section: Township: Range: Base/Meridian: <br /> *0' erator(Business Owner)informatia�u <br /> Person/Operator Name/Company Name:Holly Commerce Center,LLC <br /> Last Name:Cortese First Name:Steve MI: <br /> Title:Managing Member Organization: <br /> Mailing Address:21 Lafayette Circle,Suite#200 <br /> City:Lafayette State:CA Zip: ® � ® ❑9 — © 0 ❑9 <br /> Phone Number: (925 ❑� ® �- a a o a FAX:( ) [1E111- ❑ ❑ ❑ ❑ <br /> E-Mail Address: <br /> P*Land Owners) [Plroperty,4w4er(s)]Information <br /> Person/Operator Name/Company Name:Holly Commerce Center,LLC <br /> Last Name:Cortese First Name:Steve MI: <br /> Title:Managing Member Organization: <br /> Mailing Address:21 Lafayette Circle,Suite#200 <br /> City:Lafayette State:CA Zip: ❑9 ® ❑5 ® 0— ❑� © ❑� <br /> Phone Number: (925 FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> Email Address: <br /> fsa ' 'i Ii li .4110` <br /> r�� �C- �- - _ <br /> NO_. altre fors, >� l© i i >< #►, p > tt> g;dt►eumsttd la ` <br /> ,,� �) fp <br /> LEA or Operator or Owner signature: X Phone:2� 16C�` Y ate: Z✓ ^ <br /> ❑Supporting documents attached ❑Maps attached ❑All signatures and dates present on documents <br /> See :httR://www.calrecycle.ca.gov/SWFacilities/Directory/MiniMEMDala.A U <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> MIS <br /> 10-2 cr�»lt t��5 mit. Char C(1 _pet`Fi _ <br /> Unit Activity(s)name(s)and Code#: <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: <br /> Reaulatory Status Operator Type Operational Status Inspection Frequency:None <br /> ❑Permitted ❑Federal []Planned Closure year(date):2017 <br /> ❑Unpermitted ❑State ❑Active TonsNolume per Day:0 <br /> ❑Exempt ❑County ❑Inactive Permit Date: <br /> ❑■EA Notification ❑City ❑Q Closed EA Notification date:10/10/2016 <br /> ❑Excluded ❑I 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 />