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State of California Soli4aste Information System (SOS) Department of Resources Recycling CalRecycle 37(Rev.12/17) and Recovery(CalRecycle) Facility/Site/Operation Data Entry Form [:]*** New SWIS Number Update information(*❑ )ElChange in address or phone#SD Request to Archive CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number 39 _CR _0042 /LEA 39 -AA *Facility Locator Information see: Minimum Data Required to Issue New SWIS Number Facility/Site Name:Mulhair Disposal Site Facility/Site Location/Address:19133 E.Liberty Road Nearest City/Place Name:Clements County:San Joaquin State Zip:95227 _ Facility locator info: Decimal Degrees=Longitude: - Latitude ❑3 ® . 2❑ ❑s © © -or- Degrees,Minutes,and Seconds: Long:- Lat: Assessor Parcel Number(s):00911Oil Map#: Section: Township: Range: Base/Meridian: ❑* Operator(Business Owner) Information Person/Operator Name/Company Name: Last Name:Mulhair First Name:William MI: Title: Organization: Mailing Address:19133 E.Liberty Road City:Clements State:CA Zip: 99 0 0 ❑7 - ❑ ❑ ❑ ❑ Phone Number: ( ) ❑ ❑ El- ❑ ❑ ❑ ❑ FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ E-Mail Address: X* Land Owner(s) [Property Owner(s)]Information Person/Operator Name/Company Name:Andres Gomez,Olga Gomez Last Name:Gomez First Name:Andres,Olga MI: Title: Organization: Mailing Address:179 Bismark Street City:Daly City State:CA Zip: ❑9 ® M 1❑ ®- ❑ ❑ ❑ ❑ Phone Number: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ FAX: ( ) E1110- ❑ ❑ ❑ ❑ Email Address: ***Required Signature for submittal to Ca cycle with supporting documents and maps: ' 209-468-3284 5/7/2018 LEA or Operator or Owner signature: X Phone: Date: OSupporting documents attach6d ❑Maps attached ❑All signatures and dates present on documents See :http://www.calrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx ------------------------------------------------------------------------------------------------- ----------------- F1*Facility/Site/Unit: Characteristics/Specifications: Unit Activity(s)name(s)and Code#: (See back of this form for list of Activity types and codes) Check one each: Regulatory Status Operator Type Operational Status Inspection Frequency:Quarterly ❑Permitted ❑Federal ❑Planned Closure year(date): ❑E Unpermitted ❑State ❑Active TonsNolume per Day: ❑Exempt ❑County ❑Inactive Permit Date: ❑EA Notification ❑City ❑■Closed EA Notification date: ❑Excluded ■❑ Private ❑Clean Closed ❑Proposed ❑District ❑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