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State of California Sold W e Information System (SWI-, California Integrated Waste CIWMB 37 (Rev. 01/2008) Facility / Site /Operation Data Entry Form Management Board E1* * * New SWIS Number ❑ Update information(*El Change in address or phone #s ❑ Request to Archive CIWMB USE ONLY = Facility/Site/Operation SWIS Number A- CR - Ob t / LEA -_ ❑* Facility Locator Information: ,2see: http:/, U Facility/Site Name:_ (wh-e-e✓ yam/ Facility/Site Location/Address: a Z 1. / t7 �1�✓l f�l� Nearest City/Place Name: 1-� aICYJ `tbrr County: San oa- PIrlState ❑ Zip: q156-86' Facility locator info: Decimal Degrees = Longitude: - ❑ ❑ ❑ . ❑ ❑ ❑ ❑ ❑ Latitude ❑ ❑ . ❑ ❑ ❑ ❑ ❑ -or- Degrees, Minutes, and Seconds: Long: - Lat: Assessor Parcel Number(s): 0011, 03q Map#: Section: Township: Range: Base/Meridian: ❑* Operator (Business Owner) information: (� Y,& n Person/Operator Name/Company Name: Geoca o V 6Lr w.ciw'mb.ca. ov/SWISL1VTinimumllata.htm r i ✓A.te Last Name: �ar ber First Name: e e MI: Title: 0 Wel e V'- Organization: Mailing Address: Pd C-"0 X City: 111 cNn-rOn State: C1 Phone Number: 1114 - 4 ® [4 Q FAX: E- Mail Address: �* Land Owner(s) [Property Owner(s)] information: Person/Operator Name/Company Name: Last Name: Kbct,- First Name: V ii MI: Title: t/lk Y' Organization: ) ❑❑❑- ❑❑❑❑ ■■■■ Mailing Address: I 0 13(D iq ,3 `41 13.eVison F� rtr y 26t City: f -ov) State: CA Zip: ® 151 V - ❑ ❑ ❑ ❑ Phone Number: ® Q Q ® FAX: ( ) ❑ ❑ ❑ - ❑ ❑ ❑ ❑ E- Mail Address: ***Required Signature for submittal to CIWMB with supporting documents and maps: LEA or Operator or Owner signature: X Phone:Po')(o$'- 99 ate: Supporting documents attac ed INIaps attached ❑All signatures and dates present on documents ee: ttgrihvww.cit�mir.ea.goe•/SWI5/ivlinimunrl:hua.h(n ------------------------------------------------------------- ----------------------------------------------------- ❑* 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: Reeulatory Status Operator Type operational Status Inspection Frequency: ❑ Permitted ❑ Federal ❑ Planned Closure year (date): /95� ❑Unpermitted ❑ State ❑ Active TonsNolume per Day: J'InExempt County ❑ Inactive Permit Date: ❑ EA Notification ❑ City "9Closed EA Notification date: 13 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 CIWMB staff Signature (Received and Reviewed for completeness) by: X Phone: Date: