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1 <br />L <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />11 <br />12 <br />13 <br />14 <br />15 <br />16 <br />17 <br />18 <br />19 <br />20 <br />21 <br />22 <br />23 <br />24 <br />25 <br />26 <br />27 <br />28i <br />Nonhazardous Petroleum Contaminated Soil Regulatory Requirements <br />Approved by Office of Administrative Law - March 25, 1996 <br />Effective April 24, 1996 Page 5 <br />APPENDIX CSSP <br />State of California California Integrated Waste <br />CIWMB FORM 90 (new 8/95) Management Board <br />STANDARDIZED CONTAMINATED SOIL SOLID WASTE FACILITIES PERMIT <br />1. Facility/Permit Number (SWIS): <br />2. Facility Name: <br />Address/Location: <br />3. Enforcement Agency: <br />Address: <br />4. Signature of Enforcement Agency Approving Officer: <br />6. Date Signed: <br />5. Please Print or Type Name and Title of Approving Officer: <br />7. Date Received by CIWMB: <br />S. Signature of CIWMB Approving Officer: <br />10. Date Signed: <br />9. Please Print or Type Name and Title of Approving Officer: <br />11 . Date of Permit Issuance: <br />12. Permit Review Due Date: <br />The facility for which this permit has been issued shall only be operated in accordance with the description <br />provided in the application pursuant to Section 18105.1 and Report of Contaminated Soil Disposal Site <br />Information pursuant to Section 18224. <br />