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State of California Soli(&aste Information System (*IS) California Department of Resources <br /> CalRecycle 37(Rev.4/2016) Facility/Site/Operation Data Entry Form Recycling and Recovery(CalRecycle) <br /> ❑■ *** New SWIS Number E]Update information (*❑ ) ❑Change in address or phone#s ❑Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number - - /LEA - <br /> ❑* Facility Locator Information see: http://www.caIrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx <br /> Facility/Site Name: F'ac k-\"\ 9- t 0 vet's/ <br /> Facility/Site Location/Address: 2OSbo \-�O\ky <br /> Nearest City/Place Name: County: State CAZipAS3o� <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 /> ❑ Operator(Business Owner)=Information <br /> Person/Operator Name/Company Name: <br /> Last Name: .Px.\ ,:XT C-.P - First Name: MI: <br /> 01 <br /> Title: GIP C) Organization: <br /> Mailing Address: O. Eox 26�A 3 <br /> City: V ti,nn C1 State: (1k Zip: ® © ® ® 7- 116K15 <br /> Phone Number: (S 1 a ) 7❑ © ®- 16 ® ❑7 VI FAX: ( ) [] [] I]- ❑ ❑ ❑ ❑ <br /> E-Mail Address: V v, '%vN 1 oV10oo\c.., Cove. <br /> ❑* Land Owner(s) [Property'Owner(sj] Information <br /> Person/Operator Name/Company Name: Nn1kNi cg:r\ . LL C- <br /> Last <br /> Last Name: Code. First Name: s Zvi MI: A. <br /> Title: Nh^0<;.,c M �( Organization: <br /> Mailing Address: 'L1- �e,��-�_ 206 n <br /> City: State: L Zip: ❑ © �© Q- © ® ® ❑9 <br /> Phone Number: (q IS ® It N- 190 0 17 FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> Email Address: <br /> ***Required Signature for sl bmittal to CalRecycle with supporting documents'a`nd maps;:; <br /> LEA or Operator or Owner signature: X / r/!> '/ / Phone:?, -A8-S?_VDate: to 1 l(� <br /> N Supporting documents attache n Maps attached JA All signatures and dates present on documents <br /> See:http://www.calrecycle.ca.2ov/SWFacilities/DirectorvMinimumData.asl)x <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> ❑* Facility/Site/Unit: Characteristics/Specifications: p ` - <br /> Unit Activity(s) name(s)and Code# y,— C" AV!�S <br /> (See back of this form for list of Activity types and code's) <br /> Check one each: <br /> Regulatory Status Operator Type Operational Status Inspection Frequency: <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): <br /> ❑Unpermitted ❑State Active TonsNolume per Day: ZS3h wf�:C_)PIC�6 <br /> Exempt ❑County Inactive Permit Date: <br /> EA Notification ❑City ❑Closed EA Notification date: ko/l0 2-a1b <br /> Excluded IL Private ❑ Clean Closed <br /> ❑Proposed I IDistrict ❑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#): Ma't'2S�Q\S <br /> ***Required CalRecycle staff signature(Received and reviewed for completeness) <br /> by: Phone Date <br />