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of California SolidWStateste Information System (S RIS) California Department of Resources <br /> CalRecycle 37(Rev.4/2012) Fty/Site/Operation Data Entry ?ornW Recycling and Recovery <br /> *** New SWIS Number El Update information(*❑ ) ❑ Change in address or phone#s E] Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number - - /LEA - <br /> ' _" see: ttp:// .ealrecycle.ca.gov/S Facilities/ irectory if►i u ata.as x <br /> Facility/Site Name: Tm(�ria� W��-�r n f(v�,u.G� <br /> Facility/Site Location/Address: a0500 S� �0�� U <br /> Nearest City/Place Name: 1 (Lt�,✓� County: CAP Senjk;^ State CA Zip:IS30 - <br /> Facility locator info: Decimal Degrees= Longitude: - ❑ ❑ 11 . ❑ ❑ ❑ ❑ ❑ Latitude ❑ 11 . 11 ❑ ❑ ❑ ❑ <br /> -or- Degrees, Minutes, and Seconds: Long: - Lat: <br /> Assessor Parcel Number(s): a la'(0 10 <br /> Map#: Section. Township: Range: Base/Meridian: <br /> Person/Operator Name/Company Name: �tM(k ri 41 "ern Pso�,l �/J 3 <br /> Last Name: P►(-Q-S First Name: m PCNL Lil MI: <br /> Title: M w)v,,r1,_1- Organization: <br /> Mailing Address: \0.0,1 bo". 110 <br /> City: lco U CNn't Gln State: (°A Zip: ® ® Q ® ®- ❑ ❑ ❑ ❑ <br /> Phone Number: ® ®- 1� ® © A FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> E-Mail Address: <br /> Person/Operator Name/Company Name: <br /> Last Name: First Name: MI: <br /> Title: Organization: <br /> Mailing Address: Lk+CA(A r� C. CI fG il(� <br /> City: LAq,tgLC. State: C Zip: ® ® ® ® ®- ❑ ❑ ❑ ❑ <br /> Phone Number: (ya,S) ® It ®- ® '1❑ 111 FAX: ( ) 1111 ❑- ❑ ❑ ❑ ❑ <br /> Email Address: <br /> LEA or Operator or Owner signature: X Phon ola�A%-3)'71-317`d-Date: 3 8 }� <br /> Supporting documents attach CK Maps attached a<All signatures and dates present on documents <br /> See: ttp://www.calrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> i4 <br /> "-it <br /> vity(s) names)and Code � Cr <br /> M+ r <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: 1 <br /> Regulatory Status Operator Type Operational Status Inspection Frequency:_ (91AAl 4 AA <br /> ❑ Permitted 11 Federal ❑ Planned Closure year(date): <br /> ❑ Unpermitted ❑ State Active TonsNolume per Day: 3--] ons otu�t <br /> ❑ Exempt ❑ County ❑ Inactive Permit Date: <br /> LIK,EA Notification ❑ City ❑ Closed EA Notification date: <br /> F1 Excluded tfePrivate 11 Clean Closed <br /> ❑ Proposed ❑ District ❑ To be Determined <br /> List one or more Types of Waste to be received/permitted(see back of this form for list of waste types/code#): ap�jP�f, L4rJ 1�� <br /> ***Required CalRecycle staff signature(Received and reviewed for completeness) <br /> by: Phone Date <br />