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State of California Solid aste Information System ( S) California Department of Resources <br /> CalRecycle 37(Rev.4/2016) Facility/Site/Operation Data Entry Form Recycling and Recovery(CalRecycle) <br /> ❑*** New SWIS Number MUpdate information (*❑ ) ❑Change in address or phone#s ❑Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number 3 9 - -®o /LEA 39 -AA <br /> ❑'� c> Ltrc t� n� �cma o see: htt ://www.calrecycle.ca.gov/S Facilities/ irectorv/ ini a ata.as x <br /> Facility/Site Name: uot+e,� ' ukvv"C_ ctoW,A64,y <br /> Facility/Site Location/Address: 57013 W, Vk,\Va- vex-y�- <br /> Nearest City/Place Name: 1t- County: vim State CA Zip. Tog-947-9�Z3 <br /> Facility locator info: Decimal Degrees=Longitude: - ❑ ❑ L1 . ❑ ❑ ❑ ❑ ❑ Latitude ❑ ❑ . 1111 ❑ ❑ ❑ <br /> -or- Degrees,Minutes,and Seconds: Long: - Lat: <br /> Assessor Parcel Number(s): 2.131®o3 7 <br /> Map#: Section: Township: Range: Base/Meridian: <br /> 17777777777777 �,g, <br /> ' U erator usiness>Qwlaernfor(14 <br /> aaran <br /> Person/Operator Name/Company Name: ale <br /> Last Name: First Name: 1�a�` MI: <br /> Title: K o..v.c.� C-OC�w�0.h Organization: <br /> Mailing Address: 103o Lc,&:& Rpac\ <br /> City: State: �� Zip: K ® ® <br /> Phone Number: (Zo6l ) '9110 - 0 ® ® ❑1 FAX: ( ) El 11 ❑- 1111 El El <br /> E-Mall Address �2wSex� Ka�c16�1�1t��c�. C[,hn <br /> ❑*Z,anc �er���]P>k�trpert�y Qwl�e�r(s}�Inforl��tio � <br /> Person/Operator Name/Company Name: �o��e. ut �co tee, <br /> Last Name: First Name: MI: <br /> Title: Organization: <br /> Mailing Address: 1® 3 b L��A r� 2.0 <br /> City: State: CA Zip: ® ® ® ®- ® � ® 7❑ <br /> Phone Number: (]o ) ® 'K ®- It ® ® 0 FAX: ( ) ❑ ❑ ❑- ❑ ❑ ❑ ❑ <br /> Email Address: <br /> *Required Signature r ubm tat fo CalRecycle.with` upga gud©cCm6' aid maps=: <br /> LEA or Operator or Owner signature: X Phone:2o`-`(�g 3ZZ P-�ate: 1Z ® 6 <br /> ❑ Supporting documents attac ed ❑Maps attached ❑All signatures and dates present on documents <br /> See:hqp://www.calreevele.ca.gov/SWFacHides/Directo /MinimumData.asnx <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> ❑'�''Fac�l�� " f Qhar`aeterist>f"��s fSpeca<fication <br /> Unit Acty(s) names)and Code#: tam(nW,pp tj ®oma C os'tZ U� <br /> (See back of this form for list of Activity types and co es) <br /> Check one each: <br /> Regulatory Status Operator Type Operational Status Inspection Frequency: <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): <br /> ❑Unpermitted ❑State Active TonsNolume per Day: 4(yn W `J rLC <br /> ❑Exempt ❑County Inactive Permit Date: <br /> ❑EA Notification ❑City ❑Closed EA Notification date: t.130 Zoo <br /> ExcludedNDistrict <br /> Private ❑ Clean Closed <br /> Proposed ❑To be Determined <br /> List one or more Types of Waste to be received/permitted(see back of this form for list of waste types/code#): 1 3 V�r)p,ao V C'e_ <br /> ***Required CalRecycle staff signature (Received and reviewed for completeness) <br /> by: Phone Date <br />