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State of California SolidWaste Information System (S&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 Update information (*❑ ) ❑Change in address or phone#s ❑Request to Archive <br /> CALRECYCLE USE ONLY=Facility/Site/Operation SWIS Number 3 01 -A A - 00`19 /LEA 31 -A ""T <br /> ❑*Facility Locator Informattori see: http://www<calrecycle.ca.uov/SWFacilities/ irectory/ i i ta.as x <br /> Facility/Site Name: W evsk-e % Qrc :G� 4.�-' �i-r�y Wim\ 06a_f& <br /> Facility/Site Location/Address: �A?\13 CAA r Ae-\.' <br /> Nearest City/Place Name: County: ;o,Y\ Tow :h State CA Zip:95Z0(:.-3906 <br /> Facility locator info:Decimal Degrees=Longitude: - 111111 . ❑ ❑ ❑ ❑ ❑ Latitude ❑ ❑ . 111111 ❑ ❑ <br /> -or- Degrees,Minutes, and Seconds: Long: - Lat: <br /> Assessor Parcel Number(s): 1`t3 O'Lc�p <br /> Map#: Section: Township: Range: Base/Meridian: <br /> ON <br /> Person/Operator Name/Company Name: WoeakgM <br /> Last Name: First Name: JRSUS MI: <br /> Title: \)l Ot`cam �\s k Organization: <br /> Mailing Address: `43 ANC' iVN\'9 <br /> City: State: C Zip: <br /> Phone Number: (ZA ) ® ® �- ® °1❑ ® ® FAX: (-Z ) ❑a1 ® Q- ® ® ® <br /> E Mall Address a kAp ® ® weAV CO wN <br /> ❑* :,and Uwner(s} [Property'©�wnelC(s�£���fm. ��h�n' <br /> Person/Operator Name/Company Name: falckw.Arty �:2�`J Tv�G. <br /> Last Name: First Name: MI: <br /> Title: Organization: <br /> Mailing Address: P.O. 3y <br /> City: ;prey\ State: G Zip: <br /> Phone Number: ( ) ❑ Ell]- ❑ Ell] ❑ FAX: ( ) ❑ ❑ ❑- 110 Ell] <br /> Email Address: <br /> LEA or Operator or Owner signature: X Phone:Zoq- l��-JZg 1 Date: `� 1 /16 <br /> ❑ Supporting documents attach d ❑Maps attached All signatures and dates present on documents <br /> See:h ://www.calrecycle.ca.eov/SWFacilities/Directory/MinimumData.aspx <br /> ------------------------------------------------------------------------------------------------- ----------------- <br /> ❑� <br /> Unit Activity(s) name(s)and Code#: <br /> (See back of this form for list of Activity types and codes) <br /> Check one each: <br /> Re¢ulatory Status operator Tyne Operational Status Inspection Frequency: 0 o v%2. <br /> ❑Permitted ❑Federal ❑Planned Closure year(date): 2.c:>16 <br /> ❑Unpermitted ❑State ❑Active TonsNolume per Day: <br /> ❑Exempt ❑County ❑Inactive Permit Date: <br /> � <br /> EA Notification [-]City Closed EA Notification date: 11 152A®L1 <br /> Excluded 9 Private M Clean Closed <br /> ❑Proposed ElDistrict ❑To be Determined <br /> List one or more Types of Waste to be received/permitted(see back of this form for list off waste types/code#) <br /> ***Required CalRecycle staff signature (Received and reviewed for completeness) <br /> by: Phone Date <br />