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i <br /> STATE OF CALIFORNIA ( TO: <br /> ornia Integrated Waste Management Board <br /> WASTE TIRE REGISTRATION STATEMENT 10209th Street <br /> CIWMB 401 (NEW 1-90) Sacramento,CA 95814 <br /> PUBLIC• HEALTH SERVICES <br /> San Joaquin i:r-t_Inty <br /> P. O. Boy. 2tILi� <br /> 1601 East Hazelton Avenue <br /> SECTION A — BASELINE INFORMATION St.acktanj California 952171 <br /> 1. Records provided to the Board indicate the waste tire stockpile location, ownership, and operator are as follows. Please <br /> correct any mis-information on the form. <br /> PHYSICAL DESCRIPTION OF THE FACILITY[GC 66799.71(f)] <br /> FACILITY NAME n FACILITY NUMBER <br /> PROPERTY ADDRESS(STREET) (CITY) (STATE) (ZIP CODE) <br /> ADDRESS <br /> (COUNTY)� J PARCEL NO. <br /> L) /G' _ <br /> A. Include a site location map Including section,township, range,and gitd boundaries. <br /> B. Include a site layout drawing, showing size and location of all pertinbnt manmade and natural features of the site <br /> (including facilities, roads, fire lanes, ditches, berms, wastd tire storage areas, structures, wetlands, floodways, and <br /> surface waters). <br /> NAME ILAST NAME) (FIRST NAME) <br /> (MIDDLE NAME) <br /> OWNERS ADDRESS(STREET) <br /> ADDRESS � <br /> IGC 66799.71(a)] / o Aw l0 7 <br /> (CITY) (STATE) (ZIP CODE) <br /> NAME(LAST NAME) (FIRST NAME) (MIDDLE NAME) <br /> OPERATOR �l c / f� 11 /E . <br /> (pmson responsible ADDRESS(STREET) <br /> for the overall <br /> operation of the <br /> waste lire stockpile S �', 1— <br /> (GC 66799.71(b)) (CITY) (STATE) <br /> J1 ^ (ZIP CODE) <br /> NAME(LAST NAME) (FIRST NAME) (MIDDLE AME) <br /> EMERGENCY <br /> CONTACT <br /> PERSON 24 HOUR EMERGENCY PHONE NUMBER <br /> IGC 66799.71(c) <br /> ci3 / - 5753 <br /> Government Code§66799.70 requires a Complete rbglstration statement from any"person who at <br /> NUMBER any time in a calendar year stores or stockpiles mofh than 500 waste tires at a specific location and <br /> OF from any owner or operator of any existing Waste tirb facility with a stockpile of 1500 or more waste <br /> TIRES tires." lease Indicate the number of tires stored,stockpiled,or present on this subject property on <br /> IGC 66799.701 the date registration Is completed and filed with the Board. <br /> (NUMBER OF TIRES) <br /> (OVER PLEASE) <br />