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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 PERMIT/WASTE 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 completing this application form in a complete and correct manner. <br /> FOR t7FFl IAL USE ONLY <br /> NUMBER: FILING FEE: RECEIPT NUMBER: DdTE RECEfVEO;, <br /> ATEA DATE REJECTED, ACCEt�TAN E DATE OF <br /> 1[�I��v1P1rETE <br /> (�. .. ��,�' !�'��• +'�['� )CATION• <br /> DA�E. <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 1:14.PERMIT REVIEW <br /> 112. REVISION OF SWFP and/or WDRS 115.AMENDMENT OF APPLICATION <br /> L3- EXEMPTION and/or WAIVER - ®6.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 /> //0 At l / 0- e,0/1 .S tJ�A G4.14 V S�.�Zv <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 /> 061.DISPOSAL F-13.TRANSFORMATION ®5.OTHER(describe): <br /> a. TYPE: g-vel,7®7 <br /> ®2.COMPOSTING F--14.TRANSFER/PROCESSING FACILITY <br /> a. TYPE: ❑CHECK HERE IF RECYCLABLE MATERIALS ARE RECOVERED PRIOR TO TRANSFER/PROCESSING. <br /> D.CONFORMANCE FINDING INFORMATION(CIWMP): <br /> ID 1.FACILITY IS IDENTIFIED IN(Check one): <br /> SITING ELEMENT DATE OF DOCUMENT PAGE# <br /> ONONDISPOSAL FACILITY Et DATE OF DOCUMENT PAGE# <br /> 2.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 /> %1.AGRICULTURAL 176.CONSTRUCTION/DEMOLITION ®11.LIQUIDS <br /> 72.ASBESTOS ❑Friable ❑Non-friable F--17,CONTAMINATED SOILS ®12.MIXED/MUNICIPAL SOLID WASTE <br /> 73.ASH E-18.DEAD ANIMALS ®13.SEWAGE SLUDGE <br /> 74.AUTO SHREDDER 09.INDUSTRIAL ®14.TIRES <br /> F�10.INERT ®15.OTHER(describe): <br /> 75.COMPOSTABLE MATERIAL(describe): <br /> Page 1 <br />