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APPLICATIOt"i FGAIl
<br /> lEWAIT F'OR FAC!LITIES I`,E(',LI\1(NG HAOZAR OUS WAuE
<br /> �,A
<br /> 21
<br /> / Wication for:
<br /> (1) Facility Permit Njf-M)er (2) County Assessor's Parcpl Nuin,)e,
<br /> I. U�,l Operating Permit Book C- 19, flige 3
<br /> r-1 klodification of Permit _ 000 1 -7Zone EA- 10
<br /> - ' B
<br /> Change in Design
<br /> GcograPllic,d 1.3catiort of PJ61itv (4)
<br /> 0 Change in operation "7
<br /> Section —3 Range Chang -7-E—.-
<br /> ge in Owners1iip/ Dme 'ermil Issued'
<br /> Operator Township
<br /> .,.I NDBIM,
<br /> Name and Street
<br /> of Facility r F'n
<br /> OPERATon
<br /> Austin Road Clasp T
<br /> I- D ip
<br /> sosa I S i Name and Address of
<br /> 41,�
<br /> Austin Road We5� Side.) 2. '5' mile s/o Forward, Inc.
<br /> al
<br /> Road and ALIStin Road
<br /> CaliforniaStockton , CA 95206
<br /> Son joaquin County, i P.C. Box 6-36
<br /> Tvlephoji�l ( ,,.,)g)
<br /> ----.--982-)1298 Tplenhone 2 t'i66-51 92
<br /> MIM0 and Mz,ilinc Address
<br /> 'I of Lc gal Owner of Facility (7) Type of Fit-iskless 01`�--Otinq Facility
<br /> FO.rw ,rd, Sole Proprietorship EM Corporl".io-1
<br /> r'-O- BOX 6336 partnership
<br /> Stockton, CA 95,2C£> -
<br /> Nin,,o and Address 0 0,,v-1cr(s) of busir
<br /> -Ss
<br /> (MMt be address where 1,,gal notice may ')e
<br /> Gregory
<br /> 401 S. Lincoln Street
<br /> 2,'9 Stockton , CA 9�206
<br /> 1-66-51()2 TelelY one �,(-)q ) '
<br /> C,I
<br /> Ty,r,c ()f FaCility (Check all ip,v,�ptiate 1)�)
<br /> (6) TYPO Of X�W; ;'�(o,,'ved (Checl j ho,(-
<br /> and/or comuit Sic. �028,1 & &0)'-) 1
<br /> 1�j La!"C"fill ❑ S-orage �3, *Tifio 22, C„,hf, A'drn,
<br /> Ej COdr' for additional names of hazardous w;,stes.)
<br /> Pcoel Composting
<br /> t.I Rcsourco Recovery Injection Vell Acid solution Cl Solvent oil
<br /> DJ Transfe! Slati,,gi Other Alkaline solution LO Tcrra,athyi jca(j sj,�(j�c! (-I Drilling mud
<br /> EJ Pesticides El cir,rriicll to;let vvasses
<br /> Paint slu(1,9,! Tan4.boticni sollirnent -,oil rani,sand
<br /> P-
<br /> 111.1b;iC Llsr: the 'JaCilitV (10) Other: PrCs t i c i de l!,]]S I I t C! 7
<br /> TTT,
<br /> 0 yes 10 No r i i and Stro ,
<br /> See atta,:hod "Rc.pol-, of Dispc)saj Si t-e irlf--orm-ition"
<br /> !'�st of rer
<br /> aclencie's tl�ivijlq jurk(lictioll over thy. Facility.
<br /> any Permit nl;mh^rs where approp,-;,It^.
<br /> certify that. lhe inf�
<br /> '11nzition pfuvidv(I in this Z,.p;)jicFjtiojl and in the al"achnicnts (listed h0lovi) is true and to d.-
<br /> LA`51 Of my
<br /> Si�(XV11rc of Ow,ic-r
<br /> e, 519&ure of Operator
<br /> Printed
<br /> Peiflwd or
<br /> Gre�ory J.
<br /> TIT Gregor o
<br /> ODitt .r-iter,
<br /> Vice Presic!cr-,tUa I e
<br /> Vice Pres idcnt
<br /> of Rvviewer
<br /> C A L I F A ST '7
<br /> ATE DU.'AH-1 I 1WINT 01 HE.M-Tll
<br /> C r yr. Name
<br /> TYped Narru
<br /> -T,
<br /> Dat
<br />
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