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State ofCahfornia Solid Waste Information System (SWIS <br /> CalRecycle 37(Rev.7/17) Facility/Site/Operation Data i Department of Resources <br /> nttt Tnrm Recycling and Recovery(CalRecycle) <br /> ***New SWIS Number ❑Update information <br /> CALRECYCLE USE ONLY=Facility/Site/Operation❑SWIS❑NumberChange in address or phone#s ❑Request to Archive <br /> /LEA _ <br /> ❑* Facility Locator Information see: http://WWW.calrecycle.ca.gov/SFacilities/Directory/MinimumData.aspx <br /> Facility/Site Name: M �C D4t,- <br /> el <br /> Facility/Site Location/Address: E L;6eyR <br /> Nearest City/Place Name:�Q,yy1C,y^\-5 <br /> C°only: -:V% State Ca Zip: $22� <br /> Facility locator info:Decimal Degrees=Longitude: - Q 0 ,[�®0 ©© Latitude ® [�,© ® ®® <br /> -or- Degrees,Minutes,and Seconds: Long:- <br /> Assessor Parcel Number(s):Qpq 1 l pl% Lat: <br /> Map#: Section: Township: <br /> Range. <br /> ❑* Operator(Business Owner)Information Base/Meridian: <br /> Person/Operator�Nwame/Company Name: <br /> Last Name: M \ ��(' <br /> First Name: <br /> MI: <br /> Title: <br /> Organization: <br /> Mailing Address: <br /> City: (- -hne> n^ <br /> Stater Zip: 110 ❑❑ <br /> Phone Number: ( ) 0110_ ❑ ❑❑ ❑ FAX: ( } ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> E-Mai]Address: <br /> 0* Land Owner(s) [Property Owner(s)]Information <br /> Person/Operator Name/Company Name: <br /> Last Name: YL <br /> Title: First Name: <br /> MI: <br /> Organization: <br /> Mailing Address:57205 Q � - t- A c� V yz%. <br /> City:_ \lJeSr� eq�yy� 1��G� State: V\Ot`yp� <br /> Phone Number: ( ) ❑ El El- 11 ❑ ❑ El FAX: Zlp. ® ® �[�[ - ❑ ❑❑❑ <br /> Email Address: ( ) ❑ ❑ ❑- ❑ ❑ [1 ❑ <br /> ***Required Signature for s bmitt I t CalRecycle with supporting documents and maps: <br /> LEA or Operator or Owner signature:X1.46 -3zg 1 ^7 <br /> ❑ Supporting documents attached Phone: Date: �0/Z 2e[ O <br /> 181Maps attached ❑All signatures and dates present on documents <br /> See-http://wwwcalrecvde.ca.nov/SWFac lities/D'rcctorv/Min'm ---- asox <br /> ❑* Facility/Site/Unit: Characteristics/Specifications: <br /> Unit Activity(s)name(s)and Code#: 2 Z <br /> (See back of this form for list of Activ ty type a do de) <br /> Check one each: <br /> Reeulatam Status Operator Type Operational Status <br /> Inspection Frequenc <br /> y: <br /> �®❑Permitted ❑Federal ❑Planned Closure year dateWnpermitted ❑State ❑Active TonsNolume per Day:❑Exem t ❑County <br /> -- <br /> ❑Inactive Permit Date: <br /> ❑EA Notification ❑City Closed EA Notification date: <br /> ❑Excluded X Private Clean Closed <br /> ❑Proposed LjDistrict ❑To be Determined <br /> List one or more Types of Waste to he 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: <br /> Phone Date <br />