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State of California Solid%aste Information System (SAS) Department of Resources Recycling <br /> CalRecycle 37(Rev.12/17) and Recovery(CalRecycle) <br /> Facility/Site/Operation Data Entry Form <br /> ***New SWIS Number Update information (*❑ )❑Change in address or phone#sE]Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number 39 _CR —0042 /LEA 39 -AA <br /> * Facility,Locator Information see: Minimum Data Required to Issue New SWIS Number <br /> Facility/Site Name:Muinair Disposal site <br /> Facility/Site Location/Address:19133 E.Liberty Road <br /> Nearest City/Place Name:ciements County:San Joaquin State Zip:95227 _ <br /> Facility locator info: Decimal Degrees= Longitude: - 0 ❑2 1❑ .❑o ® ❑� ❑5 ❑5 Latitude ® .❑2 ❑3 © © <br /> -or- Degrees,Minutes,and Seconds: Long:- Lat: <br /> Assessor Parcel Number(s):0091'oil <br /> Map#: Section: Township: Range: Base/Meridian: <br /> ❑* Operator (Business Owner) Information <br /> Person/Operator Name/Company Name: <br /> Last Name: First Name: Ml: <br /> Title: Organization: <br /> Mailing Address: <br /> City: State: Zip: 11111111 ❑- ❑ ❑ ❑ ❑ <br /> Phone Number: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ FAX: ( ) ❑ [10- ❑ ❑ ❑ ❑ <br /> E- Mail Address: <br /> ❑O* Land Owner(s) [Property Owner(s)]Information <br /> Person/Operator Name/Company Name: <br /> Last Name:Gomez First Name:Andres,Olga MI: <br /> Title: Organization: <br /> Mailing Address:179 Bismark Street <br /> City:Daly city State: Zip: ❑9 ® 0 ❑ ®- ❑ ❑ ❑ ❑ <br /> Phone Number: ( ) 1111 ❑- ❑ ❑ ❑ ❑ FAX: ( ) ❑ ❑ ❑- 11111111 <br /> Email Address: <br /> ***Required Signature for <br /> /submittal to CalRecycle with supporting documents and maps: <br /> LEA or Operator or Owner signature: X �� ��.,�y , Phone:209-468-0338 Date:6/18/2018 <br /> ❑Supporting documents attached ❑Maps attached ❑All signatures and dates present on documents <br /> See :http://www.calrecycle.co.eov/SWFacilities[Directorv/MinimumData.asax <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> U* Facility/Site/Unit: Characteristics /Specifications: <br /> Unit Activity(s)name(s)and Code#: <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: <br /> Rezulatory Status Operator Type Operational Status Inspection Frequency:Quarterly <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): <br /> FN�Unpermitted ❑State ❑Active TonsNolume per Day: <br /> ❑Exempt ❑County ❑Inactive Permit Date: <br /> ❑EA Notification ❑City ❑■Closed EA Notification date: <br /> ❑Excluded ❑■ Private ❑ 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#) <br /> ***Required CalRecycle staff signature (Received and reviewed for completeness) <br /> by: Phone Date <br />