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�- <br /> a 4 4 a <br /> 'v_3 L'J ' i 1 Cert <br /> a <br /> STATE OF CALIFORNIA � _•�'.••✓ <br /> .;� 009.10 WASTE MANAGEMENT BOARD <br /> SOLID WASTE FACILITY PERMIT APPLICATION' <br /> .SSVIMN C-1^77 (NEW e-77) <br /> - <br /> ENFOR��na�NT Ai:ffNCe . 10 `^" F' ENFORCEMENT AGENCY USEONLY <br /> d .•-.. _` <br /> 'FILE NUMBER PERMIT NUMBS <br /> CFUNYY <br /> DATE RECRIYED PILING FEE <br /> TYPiI$� APPLICATION �/ <br /> 2. APPLICATION DATE ACCEPTED RECEIPT NUMBER <br /> 1. <br /> CE OF FOR 30 <br /> 3. <br /> OPERATION * F <br /> PERMIT WASTEOF PERM TTl�ON FOR MODIFICATION .� —__.__.__..�...._....___------- <br /> 4.AMENDMENT AMENDMENT DATE PERMIT ISSUED CO SWMP REFERENCE PARE <br /> Off <br /> OF <br /> APPLICATI6IN S. APPLICATION FOR REVIEW <br /> NOTE: This farm has been developed for multiple-uses. it is the transmittal sheet for documents required <br /> to be submitted to the enforcement agency. *A Report of Station or Disposal Site Information <br /> or an amendment thereto must be submitted with this form. <br /> OF FACILITY _ <br /> - LATIt?�a-O P' MCi6.i'tYfW -A !S DR LOCATION DESCRIPTION By SECTION.TDW NStiIP,RANEE, COtJT Y .. <br /> TYPE OF FACILITY - ....__..._..___.�_�.__..... <br /> i. <br /> SOLID WASTE DISPOSAL SITE TRANSF R/PROCESSING STATION (INCLUDRS RESCURCS,RECOVERY) <br /> YYPE of WAffiTE�TO 0 RECE/YED <br /> DESCRIPTION <br /> ! RESIDENTIAL REFuspE 21--'ONSTRUCTION/09MOLITION WASTES HAZARDOUS WASTKS <br /> or I <br /> FACILITY COMMRRCIAL SOLID WASTES S WAGE SLUDGE AGRICULTURAL WASTES <br /> ElTIRES LIQUIDS/SLURRIES SEPTIC TANK PUMPINGS <br /> fl.. OPERATION f DAFECTIYE ... PROPOSED CHANGE tCHECK 6N OR ROTM ! DATE <br /> FACILITY I DATE DATE <br /> IFRATION COMMENCED WILL COMMENCE I DESIGN OPERATION ! <br /> OWNER OF PROPERTY A iSj �� .___ P ADDRESS <br /> i ' <br /> ®P�RATDR NA ! <br /> II1. MIzT//...( _�_.. _ ADDRESS <br /> OPERATOR <br /> ADDRESS WHERE LEGAL NOTICE MAY 09 SERVED .. <br /> ___L I ._ - <br /> U.IMG FEE ENCLOSED <br /> - _._ <br /> IV. - <br /> ffi <br /> I hereby acknowledge that I have read this application and the Report of Station or Disposal Site Informa- <br /> tion, and certify that the information given is true and accurate to the best of my knowledge and belief, <br /> In operating the solid waste facility, I agree to comply with the conditions of the permit and with state <br /> and local enactments, <br /> SIGNA TUBE aNER OR A6.E NT� SIGNATURE (OPERATOR OR AGENTT.�...r.__,__. _. .�.�_. <br /> TYPED NAME ...�.. TYPD NAME <br /> TITLE <br /> CHECK APPROPR IATS EOM <br /> HPONCEMENT1 <br /> APPLICATION APPROVED ....._.___... APPLICATION DENIED <br /> ABY I�________._____-.--_______._------ <br /> .. ___.___ <br /> SIGNATURE TITLE AND PRINTSO NAME DATA'AND TULEP ONE NO. <br /> use ONLY <br /> BATE RECEIVED CHECK.APPROPRIATE EOM <br /> SOLID1 CONCUR WITH OBJECTED PERMIT <br /> PROPOS TO PROPOSED PERNIT AGENCY DENIAL UPHELD <br /> WARTS , <br /> ANAOE °r <br /> BOARD <br /> SIGNATURE TITLE AND PRINTRD NAME DATE AND TELEPHONE NO. <br /> USE ONLY <br />