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State of California California Integrated Waste CIWMB 169(Rev 4/04) Management Board ENFORCEMENT AGENCY NOTIFICATION Enforcement Agency: Official Use Only a SWIS Number: County Date Received: 1. GENERAL INFORMATION Operation Name: S rr4 Oroan iC-sLz� : LL L Address: 3�f3 /yl�.�i n/e City: �' f'D e 7-O State: Zip: 3a0 Phone: (� �'�? _ 'L/7 Cv Fax: e—Cji ��7� . 'v rr<r`i�` v STas,�rara Operator Name: .Si e rr r 4n 'es tee, Address: 1 )13 y3 e /�� /P City: .�7oGX,�� State: Zip: JS Phone: O - - el Fax: D - �?00.Z— 93 Land Owner: /}'1e n Je �r 2S Tn� Address: )00 . Ci State: Phone: 016 — c f f3 Fax: p — �d _ II. OPERATION INFORMATION Authorizing Eligibility(State Section of 14 CCR Division 7,Chapter 3 or 3.1):See back for more details Type(s)of Waste/Material Handled: �j' �o e 7- r Volume of Waste/Material Handled: Peak Loading: j ❑Cubic Yards orT ons Annual Loading: 5D® ❑Cubic Yards orxTons Days and Hours of Operation: Z;00 ,VM _ w P4 �-p Operation Acreage Brief Description of the Operation: P2 aej r nC 6?yid /1a c( I i n ' III. DOCUMENTATION OF LOCAL NOTIFICATION(check one and submit with EA Notification) ❑ Proof of Compliance with the California Environmental Quality Act(CEQA). Correspondence from the local planning department that compliance with_ Q A is not required for the operation to obtain local land use approval. ❑ Written notice to the local planning department of the operator's intent to commence operations. IV. OWNER/OPERATOR OWNER/OPERATORCERTIFICATION I hereby certify under penalty of perjury that the information provided is true and accurate to the best of my knowledge and belief. Signature of Land Owner: 7> Date: Signature of Operator: - Date: Completion of this form is not required by regulation;however,it will provide the enforcement agency with the information required by 14 CCR 18103.1. 0 A separate Notification is required for each eligible operation.