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State of California Sold�'aste Information System (� `�Pi�7) California Department of Resources CalRecycle 37(Rev.4/2012) ;•!ility/Site/Operation Data Entry Fort% Recycling and Recovery ❑*** New SWIS Number X Update information(*❑ ) N Change in address or phone#s ❑ Request to Archive CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number 39 - A0 -p b S /LEA - see: http://www.calrecycle.ca.gov/SWFacilities/Directory/MinimumData.aspx Facility/Site Name: u(Vw —l ct,4hi or Facility/Site Location/Address: qaU W. Frt-vje T' �d Nearest City/Place Name: (-all)1 op County: San J 0414111 State CA Zip:4s3'10- Facility locator info: Decimal Degrees= Longitude: - 1❑ ® © . ❑3 0❑ N ® ❑ Latitude ❑3 7❑ . ® ❑4 ® NI -or- Degrees, Minutes and Seconds: Long: - Lat: Assessor Parcel Number(s): APN W . \4 2 b OaD- Ma #: Section: Township: Range: Base/Meridian: 1 ) Person/OperaCompany Name:tor Name/ s P CGli4 L (- Last Name: First Name: MI: Title: Organization: Mailing Address: Ci Ili l�- F I c We P� Cj .1 City: L 414 rpp State: t,/+ A Zip: ❑ ❑s ❑3 ❑3 ®— ❑ ❑ ❑ ❑ Phone Number: (ac q, y❑ 1®- ® 1❑ FAX: ( .104 ❑y ® ®- ® 3❑ E-Mail Address: w r)tkl ve Dowe f. tam ' e 0S@ f Ve s Person/Operator Name/Company Name: Last Name: cJG�1 C�1�� First Name: -3-G Mf_S MI: Title: qfa oe&� n w')y— Organization: 1 Mailing Address:$ QD " M W(.s,r M City: State: CA Zip: 11 IN ❑3 ® 10— ❑ 111111 Phone Number: (ao 1 ) 151 M- © © ® © FAX: (101 ) 10 1 S❑- ® 4J 4 Email Address: ctot. G rn LEA or Operator or Owner signature: X 62n cc1�j - t o�t) Phon d 4� - Date: B �� ❑ Supporting documents attac d ❑ Maps attached ❑ All signatures and dates present on documents See:htti)://www.calreevc[e.ca.eov/SWFacilities/Directory/MinimumData.aspx ------------------------------------------------------------------------------------------------- ----------------- UnitActivity(s) name(s)and Code#: (See back of this form for list of Activity types nd code 8.6. Check one each: Regulatory Status Operator Type Operational Status Inspection Frequency: M x141 PlIkermitted ❑ Federal ❑ Planned Closure year(date): Ulnk,lnvk4n ❑ Unpermitted ❑ State Active TonsNolume �ay: SOD -fans 11 Exempt County ❑ Inactive Permit Date: l la Ili ❑ EA Notification ❑ City ❑ Closed EA Notification date: ❑ Excluded ❑ Private ❑ Clean Closed ❑ Proposed ❑ District ❑ To be Determined I List one or more Types of Waste to be received/permitted(see back of this form for list of waste types/code#): (`0M905k (('�nj ' &tj l�jt�t LfQt,),t0e�(A,-WSO, CIJt debt'S� ***Required CalRecycle staff signature (Received and reviewed for completeness) by: Phone Date