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1% <br /> ' Mate of California California Integrated Waste <br /> CIWMB 169(Rev 4/04) Management Board <br /> ENFORCEMENT AGENCY NOTIFICATION <br /> Enforcement Agency`° „� Official Use"4niy_ , <br /> SWIS Number <br /> County: Date Received: <br /> A' 4,1 FO <br /> Operation Name: s 1-e rr ' Orodn®rod `Cs L) : LL r <br /> Address: �/��i'n l� Ctty:. .S tOC fo Sta#e:�� Zip _ 30 <br /> Phone d j_ �'� - �9�w . 2 40 -eiP Z/ <br /> Operator Name: I'e rr r 4n t?;_s L408 , Z_ <br /> C 9 .2 4? <br /> J <br /> Address ���/3 /�/` /, _ ! ` .� alf� <br /> Phone. 1,,2 0 - 3 09_ d'�— 93 <br /> Ladd Owner. h 1,ek)d a Ptr e S 2nd <br /> lei <br /> Address: o B t ; Stater <br /> 11 <br /> Phone: L2oc <br /> ;r ItA�►TI©I INFORMATION <br /> Authorizing Eligibility(State Section of 14 CCR Division ,C fen 3 or 3,1):See back for more details <br /> Type(s)of Waste/Material Handled: �j' e e 7-rod A� <br /> Volume of Waste/Material Handled: i4eg rax le 7-j-r s Rer da <br /> Peak Loading: ❑Cubic Yards or Tons AnnualLOadtng: `. S"Od ❑Cubic Yards orxTons <br /> Days and Hours of Operation: 7.'OV #In _ A) /'00 yy/ Operation;Acreage: <br /> Brief Description of the Operation:. <br /> 2 .-O,i t)i yie Tre 01 <br /> Re-load injj aind hou l in T eS in Stn s <br /> III.`DOCUMENTATION F L.� UTIFfC,:TION (check one and sub��oit v,ith�A Notificatieri) <br /> a <br /> V <br /> ❑ Proof of Compliance with the Califor", Quality Act(CEQA) <br /> Correspondence from the local pl,I t i i ent that compliance with�CEQA is not required for th <br /> obtain local land use approval. ,� �' "° <br /> ❑ Written notice to the local planning department of theoperator'sintent tocommence operations � <br /> IV. OWNERIOPERATOR CERTIFICATION <br /> I hereby certify under penalty of perjury;that the information provided is true and accurate to the best of my knowledge and belief. <br /> Signature of Land Owner: Date: <br /> N � <br /> Signature of Operator: __,__.__ date: <br /> d <br /> Completion of this form is not required by regulation;howeykit will provide the enforcement agency with the information required by 14 CCR 18103:1. <br /> • A separate Notification is required for eactgilile operation. <br />