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STATE OF CALIFORNIA <br /> CALIFORNIA,`;NTEGRATED WASTE MANAGEMENT BOARD <br /> RIIGIONAL WATER QUALITY CONTROL BOARD <br /> APPLICATION FOR SOLID WASTE FACILITY PERMITMASTE DISCHARGE REQUIREMENTS <br /> CIWMB E-1-77(Rev.6-04) <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 OFFICIAL USE ONLY <br /> WIS NUMBER': FILING FEE:i RECEIPT NUMBER: DAT£RECEIVED: <br /> S`/a,? <br /> ATEA DATE REJECTED: ACCEPTANCE DATE OF <br /> INCOMPLETE <br /> APPLICATION: <br /> e DATE DUE! <br /> Part 1.GENERAL INFORMATION <br /> A.ENFORCEMENT AGENCY: B.COUNTY: <br /> C.TYPE F APPLICA FION(Check one box only): 401 <br /> 1. NEW SWFP and/or WDRS 4.PERMIT REVIEW <br /> R2. REVISION OF SWFP and/or WDRS 5.AMENDMENT OF APPLICATION <br /> 3. 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 /> e. AAA0�15Ao0o' 692 S;a.7 4P <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 /> IX 1.DISPOSAL F-13.TRANSFORMATION 05.OTHER(describe): <br /> a. TYPE: r <br /> F-12.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 /> ®1.FACILITY IS IDENTIFIED IN(Check one): <br /> SITING ELEMENT DATE OF DOCUMENT PAGE# <br /> ®NONDISPOSAL FACILITY EL 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 F-16.CONSTRUCTION/DEMOLITION ®11.LIQUIDS <br /> F�2.ASBESTOS ❑Friable ❑Non-friable r17.CONTAMINATED SOILS ®12.MIXED/MUNICIPAL SOLID WASTE <br /> M3.ASH F-18.DEAD ANIMALS 1:113.SEWAGE SLUDGE <br /> 1:14.AUTO SHREDDER F-19.INDUSTRIAL ®14.TIRES <br /> ®10.INERT ®15.OTHER(describe): <br /> ®5.COMPOSTABLE MATERIAL(describe): <br /> Page 1 <br />