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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 DISC.WRGE REQUIREMENTS <br /> CIWMB E-1-77 Rev,8-04 <br /> NOTE:This form has been developed for multiple uses. It is the transmittal shee tS re ed to be submitted to the appropriate agency. <br /> Please refer to the attached instructions for definitions of terms and for co I t cation form in a complete and correct manner. <br /> FOR OFFICIAL USE ONLY :0 <br /> SIMS NUMBER: FILING FEE: RECEIPT NUMBER: DATE RECEIVED: <br /> DATE ACCEPTED: DATE REJECTED: ACCEPTANCE DATE OF <br /> INCOMPLETE APPLICATION: <br /> DATE DUE: <br /> Part 1.GENERAL INFORMATION <br /> A.E1NFQRCEMEN�,TA�GENCY Q B.COUNTY: L <br /> l s I V U I"/t EI/Lf'"1 dX1 � t CHIC 6 r1 T <br /> C.TYPE OF APPLICATION(Check one box only): <br /> 1. NEW SWFP and/or WDRS 04.PERMIT REVIEW <br /> 112. REVISION OF SWFP and/or WDRS 115.AMENDMENT OF APPLICATION <br /> 113. EXEMPTION and/or WAIVER 116.RFI/ROWD/JTD AMENDMENTS <br /> Part 2. FACILITY DESCRIPTION <br /> A. NAME OF FACILITY: <br /> B. LOCATION TION OF FACILITY: <br /> 1, PHYSICA' :DDRESS OR Lor-- '-Jr'-'-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 /> DISPOSAL (r7 ''d 4 03.TRANSFORMATION F-15.OTHER(describe): <br /> a <br /> TYPE: <br /> ;OMPOSTING �4.TRANSFER/PROCESSING FACILITY <br /> a. TYPE: 'T 1ti1 1 1 _ 0 CHECK HERE IF RECYCLABLE MATERIALS ARE RECOVERED PRIOR TO TRANSFER/PROCESSING. <br /> D.CONFORMANCE FINDING IN ORMATION(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 /> E AGRICULTURAL F-16,CONSTRUCTION/DEMOLITION F-11t.LIQUIDS <br /> E-12.ASBESTOS O Friable O Non-friable 1--17.CONTAMINATED SOILS M12.MIXED/MUNICIPAL SOLID WASTE <br /> M3.ASH F-18.DEAD ANIMALS F-113.SEWAGE SLUDGE <br /> F-14.AUTO SHREDDER 1--19.INDUSTRIAL F-114.TIRES <br /> 1--]10.INERT �15.OTHER(describe): <br /> M5.COMPOSTABLE MATERIAL(describe): <br /> Page 1 <br />