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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 PERMITIWASTE DISCHARGE REQUIREMENTS <br />CIWMB E-1-77 (Rev. 8-04) <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 comDletina this aDDlication form in a comDlete and correct manner. <br />FOR OFFICIAL USE ONLY <br />SWIS NUMBER: <br />FILING FEE: <br />RECEIPT NUMBER: <br />DATE RECEIVED: <br />DATE ACCEPTED: <br />DATE REJECTED: <br />ACCEPTANCE DATE OF <br />INCOMPLETE APPLICATION: <br />DATE DUE: <br />Part 1. GENERAL INFORMATION <br />A. ENFORCEMENT AGENCY: B. COUNTY: <br />C. TYPE OF APPLICATION (Check one box only): <br />1. NEW SWFP and/or WDRS 114. PERMIT REVIEW <br />02. REVISION OF SWFP and/or WDRS 5. AMENDMENT OF APPLICATION <br />11 3. EXEMPTION and/or WAIVER 116. RFI/ROWD/JTD AMENDMENTS <br />Part 2. FACILITY DESCRIPTION <br />A. NAME OF FACILITY: <br />B. LOCATION OF FACILITY: <br />1. PHYSICAL ADDRESS OR LOCATION AND ZIP CODE: <br />2. LATITUDE AND LONGITUDE: <br />3. LEGAL DESCRIPTION OF PERMITTED BOUNDARY BY SECTION, TOWNSHIP, RANGE, BASE, AND MERIDIAN, IF SURVEYED: <br />C. TYPE OF ACTIVITY: (Check applicable boxes): <br />M1. DISPOSAL F-13. TRANSFORMATION F-15. OTHER (describe): <br />a. TYPE: <br />172. COMPOSTING r74. TRANSFER/PROCESSING FACILITY <br />a. TYPE: ❑ CHECK HERE IF RECYCLABLE MATERIALS ARE RECOVERED PRIOR TO TRANSFER/PROCESSING. <br />D. CONFORMANCE FINDING INFORMATION (CIWMP): <br />F-11. FACILITY IS IDENTIFIED IN (Check one): <br />SITING ELEMENT DATE OF DOCUMENT PAGE # <br />ONONDISPOSAL FACILITY EL DATE OF DOCUMENT PAGE # <br />F2. 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 />F-11. AGRICULTURAL F-16. CONSTRUCTION/DEMOLITION F-111. LIQUIDS <br />F-12. ASBESTOS ❑ Friable O Non -friable F-17. CONTAMINATED SOILS F-112. MIXED/MUNICIPAL SOLID WASTE <br />M3. ASH E-18. DEAD ANIMALS F-113. SEWAGE SLUDGE <br />F-14. AUTO SHREDDER F-19. INDUSTRIAL M14. TIRES <br />17110. INERT F-115. OTHER (describe): <br />05. COMPOSTABLE MATERIAL (describe): <br />Page 1 <br />