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State of California Solid ' este Information System (S"' ,�) Department of Resources <br /> CalRecycle 37(Rev.7/17) _ _Cility/Site/ODeration Data Entry Forn. Recycling and Recovery(CalRecycle) <br /> X*** New SWIS Number gUpdate information(*❑ ) ❑Change in address or phone#s ❑Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number---- / LEA - <br /> ❑* Facility Locator Information see: htt //www.calree ,cle.ca. ov/SWFacilities/Directory/MinimumData.aspx <br /> Facility/Site Name: ��•/�,�_ W'\<> <br /> Facility/Site Location/Address: N303, S. CC� W—\ �•Oc�,�� <br /> Nearest City/Place Name: AbV1 County:>0.1n State Ca Zip gSAD - <br /> Facility locator info: Decimal Degrees= Longitude: - Q .Q %15 15 X Latitude <br /> -or- Degrees, Minutes,and Seconds: Long:- Lat: <br /> Assessor Parcel Number(s): 207 32020 <br /> Map#: Section: Township: Range: Base/Meridian: <br /> ❑* Operator(Business Owner) Information <br /> Person/Operator Name/Company Name: f-1(7��1t�rit p��� (( •®S �+- <br /> Last Name: FU 1J First Name: MI: <br /> n <br /> Title: 't're G f(jefl-1— Organization: <br /> Mailing Address: �'A303 S. <br /> City: R.C'ato v\ r State: CIN Zip: 1565 % 0- 0000 <br /> Phone Number: (?eM) © A q- 5 16 Q 9 FAX:( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> E-Mail Address: <br /> ❑* Land Owner(s) [Property Owner(s)]Information � <br /> Person/Operator Na/me/Company Name: l <br /> Last Name: 0.kClh First Name: M0.+*e�J MI:T <br /> Title: \11,0-e <br /> / CI C2 10re4;1 JCn+ Organization: <br /> Mailing Address: VAS03 S �w <br /> . 1P6eel <br /> 11 Poxk <br /> City: ! 'SC�X1o'V\ �t State: CA Zip: ® ®5 3 Z 6- ❑ ❑ ❑ ❑ <br /> Phone Number: (ZOq ) 15 15- ® © 199® FAX: (2M ) ® ® 0- <br /> Email Address: <br /> ***Required Signature for sbmit,alt CalRecycle with supporting documents and maps: <br /> LEA or Operator or Owner signature: X Phone:248 Date: 'll1 <br /> ❑ Supporting documents attached JjMaps attached []All signatures and dates present on documents <br /> See httu://www.calrecvcle.ca.eov/SWI'acilities/Directors/NiinimumData.asux <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> ❑* Facility/Site/Unit: Characteristics/Specifications: <br /> Unit Activity(s)name(s)and Code#: 14 <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: <br /> Reeulatory Status Operator Tvoe Onerational Status Inspection Frequency: ( L <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): <br /> Unpermitted ❑State MActive Tons/Volume per Day: <br /> ]Exempt ❑County ]Inactive Permit Date: <br /> ❑EA Notification ❑City ❑Closed EA Notification date: <br /> ❑Excluded Private ❑ Clean Closed <br /> ❑Proposed NDistrict ❑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#): l)1' Z+S <br /> ***Required CalRecycle staff signature(Received and reviewed for completeness) <br /> by: Phone Date <br />