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State of California Sohd&aste Information System (SS) Department of Resources CalRecycle 37(Rev.7/]7) ility/Site/ODeration Data Entry For Recycling and Recovery(CalRecycle) X***New SWIS Number ❑Update information(*❑ ) ❑Change in address or phone#s ❑Request to Archive CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number - - /LEA - ..... .. .......... ... .. . . ... []*Facility Locator Information see: http://www.calrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx Facility/Site Name: MsAmAC D:szosaA 5�0tc. Facility/Site Location/Address: E. tri Nearest City/Place Name: Cr_V'V5 County:e4LnaoDrv�h State Ca Zip:9$2z7 Facility locator info: Decimal Degrees=Longitude: - 1❑ B 0 . ® ® © © Latitude -or- Degrees,Minutes,and Seconds: Long:- Lat: Assessor Parcel Number(s): 0001110 1% Map#: Section: Township: Range: Base/Meridian: ❑* Operator(Business Owner)Information Person/Operator^Name/Company Name: Last Name: First Name: \N-Ay'!&M MI: Title: �,` Organization: Mailing Address: ��,33 L'��C�v �CA- City: CiwwM12ri� State: Clk Zip: M & % 22_ ❑ ❑ ❑ ❑ Phone Number: ( ) ❑ ❑ ❑- 1111 ❑ ❑ FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ E-Mail Address: ❑*Land Owner(s) [Property Owner(s)]Information Person/Operator Name/Company Name: Last Name: First Name: MI: Title: Organization: Mailing Address:5720`S Ryzme:ts- Qojy� y C`"Wrt_ City: Wesh ? AiM N3e_.a-0,x State: �Ot`y0.4� Zip: ® ® 1h 1?$177- ❑ ❑ ❑ ❑ Phone Number: ( ) 1111 ❑- 1111 ❑ ❑ FAX: ( ) 000- ❑ ❑ 1111 Email Address: ***Required Signature fors bmitt 1 to CalRecycle with supporting documents and maps: LEA or Operator or Owner signature: X IZPhone:2011'46'011ftate: 1 IZ Zo9 ❑ Supporting documents attached NMaps attached ❑All signatures and dates present on documents See :http://www.calrecycle.ca.eov/SWFacilities/Directory/MinimumDats.aspx ------------------------------------------------------------------------------------------------- ----------------- ❑* Facility/Site/Unit: Characteristics/Specifications: Unit Activity(s)name(s)and Code#: 2�• (See back of this form for list of Activity types andcodes) Check one each: ` Re¢ulatory Status Operator Tvpe Operational Status Inspection Frequency �j ❑Permitted ❑Federal ❑Planned Closure year(date): �Llnpermitted ❑State ❑Active TonsNolume per Day: ❑Exempt ❑County ❑Inactive Permit Date: ❑EA Notification ❑City Closed EA Notification date: ❑Excluded X Private n Clean Closed ❑Proposed FDistrict ❑To be Determined List one or more Types of Waste to be received/permitted(see back of this form for list of waste types/code#) ***Required CalRecycle staff signature (Received and reviewed for completeness) by: Phone Date