Laserfiche WebLink
+ r <br /> State of California California Integrated Waste <br /> CIWMB 169(Rev 4104) Management Board <br /> ENFORCEMENT AGENCY NOTIFICATION <br /> Enforcement Agency: Official Use Only <br /> SWIS Number: <br /> County: Date Received: <br /> I. GENERAL INFORMATION <br /> Operation Name: <br /> Address: City: State: Zip: <br /> Phone: Fax: <br /> Operator Name: <br /> Address: City: State: Zip: <br /> Phone: Fax: <br /> Land Owner: <br /> Address: City: State! Zip: <br /> Phone: Fax: <br /> II. OPERATION INFORMATION <br /> Authorizing Eligibility(State Section of 14 CCR Division 7,Chapter 3 or 3.1):See back for more details <br /> Type(s)of Waste/Material Handled: <br /> Volume of Waste/Material Handled: <br /> Peak Loading: ❑Cubic Yards or ❑Tons Annual Loading: ❑Cubic Yards or ❑Tons <br /> Days and Hours of Operation: Operation Acreage: <br /> Brief Description of the Operation: <br /> IIL DOCUMENTATION OF LOCAL NOTIFICATION(check one and submit with EA Notification) <br /> ❑ Proof of Compliance with the California Environmental Quality Act(CEQA). <br /> El obtain <br /> from the local planning department that compliance with CEQA is not required for the operation to <br /> obtain local land use.approval. <br /> ❑ Written notice to the local planning department of the operator's intent to commence operations. <br /> IV. OWNER/OPERATOR CERTIFICATION <br /> I hereby certify under penalty of perjury that the information provided is true and accurate to the best of my knowledge and belief. <br /> Signature of land Owner. Date: <br /> Signature of Operator: Date: <br /> Completion of this form is not required by regulation;however,it will provide the enforcement agency with the information required by 14 CCR 18103.1. <br /> A separate Notification is required for each eligible operation. <br />